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.
An elderly man admitted for agitation and suicidal ideation was prescribed clozapine by psychiatry. The clozapine Risk Evaluation and Mitigation Strategy (REMS) program requires both prescribers and patients to be registered in an online database. A REMS-registered attending psychiatrist entered the initial order (12.5 mg). During the hospitalization, the medicine intern, who was not registered with the REMS program, titrated the dose to 25 mg daily and also wrote the discharge prescription.
Hardmeier A, Tsourounis C, Moore M, et al. J Healthc Qual. 2014;36:54-61; quiz 61-3.
After implementation of a barcode medication administration system at a children's hospital, adherence to institutional medication safety protocols was high and the incidence of medication administration errors appeared to be low based on direct observation.