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 - 20 of 22 Results
Jessurun JG, Hunfeld NGM, Van Rosmalen J, et al. J Patient Saf. 2022;18:e1181-e1188.
Intravenous admixture preparation errors (IAPE) in hospitals are common and may result in harm if they reach the patient. In this before-and-after study, IAPE data were collected to evaluate the safety of a pharmacy-based centralized intravenous admixture service (CIVAS). Compared to the initial standard practice (nurse preparation on the ward), IAPE of all severity levels (i.e., potential error, no harm, harm) decreased and there were no errors in the highest severity level after implementation of CIVAS.
Uitvlugt EB, Heer SE, van den Bemt BJF, et al. Res Soc Admin Pharm. 2022;18:2651-2658.
Pharmacists play a critical role in medication safety during transitions of care. This multi-center study found that a transitional pharmacy care program (including teach-back, pharmacy discharge letter, home visit by community pharmacist, and medication reconciliation by both the community and hospital pharmacist) did not decrease the proportion of patients with adverse drug events (ADE) after hospital discharge. The authors discuss several possible explanations as to why the intervention did not impact ADEs and suggest that a process evaluation is needed to explore ways in which a transitional pharmacy care program could reduce ADEs.
Ebbens MM, Gombert-Handoko KB, Wesselink EJ, et al. J Am Med Dir Assoc. 2021;22:2553-2558.e1.
Medication reconciliation has been shown to reduce medication errors but is a time-consuming process. This study compared medication reconciliation via a patient portal with those performed by a pharmacy technician (usual care). Medication discrepancies were similar between both groups, and patients were satisfied using the patient portal, which saved 6.8 minutes per patient compared with usual care.
Jessurun JG, Hunfeld NGM, Van Rosmalen J, et al. Int J Qual Health Care. 2021;33:mzab142.
… at one Dutch hospital. Implementation was associated with a lower probability of MAEs (particularly omission errors and … with barcode scanning.  … Jessurun JG, Hunfeld NGM, Van Rosmalen J, Van Dijk M, Van Den Bemt PMLA. Effect of automated unit dose …
Slikkerveer M, van de Plas A, Driessen JHM, et al. J Patient Saf. 2021;17:e587-e592.
Anticoagulants, such as low-molecular-weight heparin (LMWH), are known to be high-risk for adverse drug events. This cross-sectional study identified prescribing errors – primarily lack of dosage adjustment for body weight and/or renal function – among one-third of LMWH users admitted to one hospital over a five-month period.
Dreijer AR, Diepstraten J, Bukkems VE, et al. Int J Qual Health Care. 2019;31:346-352.
Despite their health benefits, anticoagulants place patients at high risk for medication-related harm. Researchers found that anticoagulants were responsible for 8.3% of medication errors documented in a Dutch national database, and that human behavior most commonly caused those errors. A WebM&M commentary elaborates upon the safety challenges of novel oral anticoagulants.
van der Veen W, van den Bemt PMLA, Wouters H, et al. J Am Med Inform Assoc. 2018;25:385-392.
… about two-thirds of medication administrations. They found a significant association between workarounds and medication … of this technology promotes safety effectively. A past PSNet perspective discussed workarounds on the front …
van de Plas A, Slikkerveer M, Hoen S, et al. BMJ Qual Improv Rep. 2017;6.
This commentary describes the results of a Six Sigma improvement project to reduce risks of parenteral medication administration errors that cause harm. Strategies tested included education, drug delivery modifications, and ensuring administration instructions were available.
Cheung K-C, van der Veen W, Bouvy ML, et al. J Am Med Inform Assoc. 2014;21:e63-70.
… the hospital setting. This study, which analyzed data from a national database of medication errors in the Netherlands, … poorly designed screens and displays, were at the root of a large proportion of these errors. Dr. Donald Norman, a … factors engineering field, was interviewed by AHRQ WebM&M in 2009. …
Karapinar-Carkit F, Borgsteede SD, Zoer J, et al. Ann Pharmacother. 2009;43:1001-10.
… … The process of medication reconciliation —reviewing a patient's medication regimen to eliminate unintended … of involving patients in safety efforts, which is a 2009 Joint Commission National Patient Safety Goal . …
van den Bemt PMLA, Idzinga JC, Robertz H, et al. J Am Med Inform Assoc. 2009;16:486-92.
This study discovered that medication administration at nursing homes is an error-prone process, particularly around administration techniques and wrong time errors. A past AHRQ WebM&M commentary discussed a case of a nurse who bypassed the safeguards of an automated dispensing system at a nursing facility, which led to a serious medication error.