Skip to main content

The PSNet Collection: All Content

The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.

Search All Content

Search Tips
Filter By Author(s)
Advanced Filtering Mode
Date Ranges
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Additional Filters
Displaying 1 - 11 of 11 Results
Zahl-Holmstad B, Garcia BH, Johnsgård T, et al. BMJ Open Qual. 2023;12:e002239.
Designated emergency department (ED) pharmacists are increasingly used to improve the quality of medication administration in the ED. This qualitative study explored patient perceptions of medication safety before and during an ED pharmacist-led intervention (including medication reconciliation and medication review) in collaboration with ED physicians. Participants underscored the importance of trust and responsibility but noted that it was not important who carried out these medication-related tasks, but rather that the participant received the help they needed.
Adie K, Fois RA, McLachlan AJ, et al. Br J Clin Pharmacol. 2021;87:4809-4822.
Medication errors are a common cause of patient harm. This study analyzed medication incident (MI) reports from thirty community pharmacies in Australia. Most errors occurred during the prescribing stage and were the result of interrelated causes such as poor communication and not following procedures/guidelines. Further research into these causes could reduce medication errors in the community.
Adie K, Fois RA, McLachlan AJ, et al. Eur J Clin Pharmacol. 2021;77:1381-1395.
… Eur J Clin Pharmacol … Community pharmacists play an important … and healthcare provider education. … Adie K, Fois RA, McLachlan AJ, et al. Medication incident recovery and … incident reporting system: the QUMwatch study. Eur J Clin Pharmacol. Epub 2021 Mar 2. …
Kinlay M, Zheng WY, Burke R, et al. Res Social and Adm Pharm. 2021;17:1546-1552.
Computerized provider order entry (CPOE) systems have been advocated as a strategy to reduce medical errors, but some errors persist. This narrative review identified knowledge gaps in the relationship between CPOE systems and how systems-related errors change over time. Studies suggest that system-related errors persist with long-term use of CPOE systems, but future research should explore the types of errors that occur, when they occur, and the system factors contributing to the errors.
Mekonnen AB, McLachlan AJ, Brien J-AE, et al. J Pharm Policy Pract. 2018;11:2.
Researchers conducted eight focus groups to understand how to better engage Ethiopian hospital pharmacists in medication safety. Most expressed enthusiasm about having an active role in safety as long as concerns related to space, resources, and training were addressed. A recent PSNet perspective examined team-based approaches to improving safety during hospital discharge.
Westbrook JI, Li L, Hooper TD, et al. BMJ Qual Saf. 2017;26:734-742.
… … Westbrook JI, Li L, Hooper TD, Raban MZ, Middleton S, Lehnbom EC. Effectiveness of a 'Do not interrupt' bundled intervention to reduce interruptions during medication administration: a cluster randomised controlled feasibility study.  BMJ Qual …
Shaheed CA, Maher CG, Williams KA, et al. JAMA Intern Med. 2016;176:958-68.
… opioid medications for back pain. Investigators found that a significant proportion of trial participants reported … effects and that recommended opioid doses only resulted in a small and short-term decrease in pain, which is deemed …
Westbrook JI, Baysari M, Li L, et al. J Am Med Inform Assoc. 2013;20:1159-67.
… of the American Medical Informatics Association : JAMIA … J Am Med Inform Assoc … The Institute of Medicine highlighted … in their 2011 report , Health IT and Patient Safety . A growing list of unintended consequences from computerized … has emerged over the last few years. This study describes a robust classification structure for identifying …
Westbrook JI, Reckmann MH, Li L, et al. PLoS Med. 2012;9:e1001164.
Although computerized provider order entry (CPOE) systems are being more widely implemented and appear to reduce medication errors, little data exists on the effectiveness of specific CPOE systems. This study evaluated the implementation of two widely used off-the-shelf CPOE systems (with limited decision support) and found that both resulted in significant reductions in serious medication errors. The article also details types of new errors induced by CPOE systems, which, while common, were generally not clinically significant. As the evidence base around implementation of CPOE systems remains relatively small, studies like this that evaluate the real-world performance of information technology are increasingly important.