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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.

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Displaying 1 - 15 of 15 Results
Cicci CD, Fudzie SS, Campbell-Bright S, et al. Am J Health Syst Pharm. 2021;78:736-742.
When patients are admitted to the intensive care unit, medication histories can be obtained from alternate sources. In this study, admission medication histories were obtained from family members or outpatient pharmacies, then compared with the history given by the patient once their delirium resolved or they were extubated. The most common type of discrepancy from both alternate sources was addition, followed by omission. Histories obtained from families had slightly fewer discrepancies, and most discrepancies were of low risk of harm.  
Zheng Y, Jiang Y, Dorsch MP, et al. BMJ Qual Saf. 2020;30:311-319.
Clinicians commonly use free-text to generate electronic prescriptions (e-prescriptions); however, these e-prescriptions often require double-checking and transcription by pharmacist staff to avoid potential medication errors. This retrospective study found that about half of the patient directions on e-prescriptions contained at least one quality issue (e.g., dose, frequency of administration) and that pharmacy staff spend significant time and effort identifying and correcting these issues.
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.
Abebe E, Stone JA, Lester CA, et al. J Patient Saf. 2021;17:405-411.
Handoffs present a significant patient safety hazard across multiple health care settings. Interruptions and distractions, which can interfere with handoff communication, are prevalent in pharmacy environments. This cross-sectional survey of community pharmacies found that virtually none of the pharmacists had received training in how to hand off information. A significant proportion of responses indicated that pharmacy information technology systems do not support handoff communication. Respondents reported that handoffs are frequently inadequate or inaccurate. The authors conclude that interventions are needed to enhance the quality of handoff communication in community pharmacy settings to prevent dispensing errors.
Shah A, Hayes CJ, Martin BC. MMWR Morb Mortal Wkly Rep. 2017;66:265-269.
Opioid use has become a growing patient safety concern. Recent studies have documented wide variation in opioid prescribing for acute pain and a significant rate of chronic opioid use after patients receive a first prescription for an acute indication. This retrospective medical record review study identified risk factors for remaining on an opioid medication for more than 1 year following their initial prescription. Older, female, and publicly or self-insured patients were more likely to remain on an opioid compared with younger, male, and privately insured patients. Patients started on higher doses (cumulative dose ≥ 700 mg morphine equivalent), provided prescriptions with longer duration (more than 10 days), or given 3 or more prescriptions for opioids were most likely to continue to use opioid medications 1 year later. The authors recommend prescribing fewer than 7 days of opioids for acute pain and adhering to the Centers for Disease Control and Prevention guideline for opioid use to improve prescribing practices.
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.
Nemeth CP, Brown J, Crandall B, et al. Mil Med. 2014;179:4-10.
This study provides a detailed description of the overlapping technological, organizational, and human factors associated with the use of smart pumps and includes insights into potential pitfalls that may pose patient safety threats. The authors make specific recommendations to improve the real-world use of smart pump technology.
Anderson CI, Nelson CS, Graham CF, et al. J Surg Res. 2012;177:43-8.
The morbidity and mortality (M&M) conference is one of medicine's most longstanding traditions. This study applied the systems approach to analyze cases presented at surgical M&M conferences over a 3-year period at one academic hospital and used insights from a modified root cause analysis process to identify common underlying problems in care. The authors categorized the majority of preventable errors as resulting from disorganized care, which included diagnostic errors, failure to rescue, and lack of situational awareness. Although M&M conferences have been criticized for failing to address systems issues, this and other recent studies demonstrate how this traditional process may be reengineered to achieve patient safety goals.
Lazarou J, Pomeranz BH, Corey PN. JAMA. 1998;279:1200-5.
The authors report a meta-analysis of 32 years of prospective studies on adverse drug reactions (ADRs). The study specifically excludes medication ordering or administration errors, focusing instead on drug toxicity, allergic reactions, and idiosyncratic adverse reactions. The authors estimate an overall incidence of 6.7% for serious ADRs in hospitalized patients and 0.32% for fatal ADRs. Using 1994 as a representative year, the authors calculate an estimated 2,216,000 serious ADRs in the United States for that year, with 106,000 fatalities, an estimate that would make ADRs between the fourth and sixth leading causes of death in the United States.