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.
White A, Fulda KG, Blythe R, et al. Expert Opin Drug Saf. 2022;21:1357-1364.
Community-based pharmacists have a critical role in ensuring medication safety in community settings. In this narrative review, the authors explored how collaboration between community-based pharmacists and primary care providers can improve medication safety. The most common collaboration strategy was medication review. The authors identified barriers to collaboration from both the primary care provider and pharmacist perspectives.
Lester CA, Flynn AJ, Marshall VD, et al. J Am Med Inform Assoc. 2022;29:1471-1479.
Although e-prescribing has improved the safety of medication ordering, preventable errors persist. This study analyzed product descriptions (ingredient, strength, dose form) of more than 10 million e-prescriptions. Results show a wide variety in the way drug product descriptions are entered into e-prescription programs (e.g., 707 variants for “oral tablet” such as tablet, tab, po tab). Poor standardization of terminology in e-prescription programs can lead to incorrect medication order and patient confusion.
Watterson TL, Stone JA, Gilson A, et al. BMC Med Inform Decis Mak. 2022;22:50.
… BMC Med Inform Decis Mak … The CancelRx system is a health information technology-based intervention intended … data from the electronic health record (EHR) system of a midwestern academic health system, researchers found that … for controlled substances. … Watterson TL, Stone JA, Gilson A, et al. Impact of CancelRx on …
Watterson TL, Stone JA, Brown RL, et al. J Am Med Inform Assoc. 2021;28:1526-1533.
Prior research has found that ambulatory electronic health records cannot communicate medication discontinuation instructions to pharmacies. In this study, the implementation of the CancelRx system led to a significant, sustained increase in successful medication discontinuations and reduced the time between medication discontinuation in the clinic EHR and pharmacy dispensing software.
Ashfaq HA, Lester CA, Ballouz D, et al. JAMA Ophthalmol. 2019.
This study examined the concordance between structured medication lists in the electronic health record and unstructured physician progress notes for antibiotic medications being used to treat keratitis, an eye infection. Researchers found that 23% of prescribed medications differed between the progress note and the structured medication list, highlighting the need for and the challenges in conducting medication reconciliation.
… efforts, evidence suggests that medication errors occur at a rate of 1.7%–22%.( 2-4 ) Of these errors, 6.5% are … medication safety in the community pharmacies should look to their colleagues who have studied safety in other … 2013;22:816-825. [go to PubMed] 13. Stone JA, Lester CA, Aboneh EA, Phelan CH, Welch LL, Chui MA. A preliminary …
This piece reviews unique characteristics of community pharmacies that can affect medication safety and spotlights the need for further research examining medication errors in community settings.
Aboneh EA, Stone JA, Lester CA, et al. J Patient Saf. 2020;16:e18-e24.
A culture of safety is vital to identifying, addressing, and preventing adverse events. Researchers delivered AHRQ's Community Pharmacy Survey on Patient Safety Culture to 445 Wisconsin pharmacists. Independent and clinic-based pharmacists reported a more robust safety culture compared to national chain pharmacists, as did pharmacists more familiar with their patients' care.
Abebe E, Stone JA, Lester CA, et al. J Patient Saf. 2021;17:405-411.
… J Patient Saf … J Patient Saf … Handoffs present a significant patient safety hazard across multiple health … had received training in how to hand off information. A significant proportion of responses indicated that pharmacy …
Aboneh EA, Look KA, Stone JA, et al. BMJ Qual Saf. 2016;25:355-63.
The Agency for Healthcare Research and Quality has developed safety culture surveys for multiple health care settings. Researchers distributed the survey to community pharmacies and found its validity to be inadequate for use in this environment. This suggests that instruments used in other settings will require significant adaptation to accurately measure patient safety in pharmacies.
Odukoya OK, Stone JA, Chui MA. Res Social Adm Pharm. 2014;10:837-852.
The handwritten prescription pad is vanishing from clinical practice, replaced by the proliferation of e-prescribing. There are many advantages to this technology, but prescribing errors still occur at alarming rates. This study explored the approaches community pharmacists and technicians utilize to detect and manage e-prescription errors.
Odukoya OK, Stone JA, Chui MA. Int J Med Inform. 2014;83:427-37.
This direct observation study found that various medication errors related to electronic prescribing occur in community pharmacies. Contributing factors included poor inter-operability between pharmacy and clinic systems, inadequate technology usability, and data entry errors. This finding underscores the growing safety concerns associated with medication prescribing in ambulatory care.
Chui MA, Stone JA. Res Social Adm Pharm. 2014;10:195-203.
This qualitative study used interviews with community pharmacists to characterize the types of latent errors that can contribute to problems with handoffs in care. Since the handoff process was not standardized, pharmacists reported encountering both information overload and a lack of accurate information when giving and receiving handoffs.
Odukoya OK, Chui MA. BMJ Qual Saf. 2013;22:816-25.
Electronic prescribing is being increasingly utilized as a patient safety strategy in ambulatory care. This qualitative study used field observations and interviews to develop a taxonomy of potential safety hazards when using e-prescribing in community pharmacies.
Odukoya OK, Chui MA. J Am Med Inform Assoc. 2012;19:1059-65.
Electronic prescribing is becoming more common in ambulatory care. This qualitative study used interviews with retail pharmacists and pharmacy technicians to identify potential safety hazards in the design of electronic prescribing systems.