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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 - 13 of 13 Results
Barrett AK, Sandbrink F, Mardian A, et al. J Gen Intern Med. 2022;37:4037-4046.
Opioid medication use is associated with an increased risk of adverse events; however research has shown sudden discontinuation of opioids is also associated with adverse events such as withdrawal and hospitalization. This before and after study evaluated the impact of the VA’s Opioid Safety Initiative (OSI) on characteristics and prescribing practices. Results indicate that length of tapering period increased, and mortality risk decreased following OSI implementation.
Russ-Jara AL, Luckhurst CL, Dismore RA, et al. J Gen Intern Med. 2021;36:2212-2220.
Resolving medication errors often requires coordination between different care providers. This qualitative study examined medication safety incidents at one VA hospital and found that health care providers rely on cognitive decentering, collaborative decision-making, back-up behaviors, and contingency planning to coordinate care during medication safety incidents. The primary barriers to care coordination identified were role ambiguity, breakdowns in care, and electronic health record-related challenges.
Zacher JM, Cunningham FE, Zhao X, et al. Am J Health-Syst Pharm. 2018;75:1460-1466.
Look-alike and sound-alike medications are known to increase the risk of adverse drug events. Using Veterans Affairs administrative data on prescriptions filled for look-alike and sound-alike medications, researchers found that the potential for medication errors was high, but the actual error rate based on chart review was low.
Radomski TR, Bixler FR, Zickmund SL, et al. J Gen Intern Med. 2018;33:1253-1259.
State-based prescription drug monitoring programs are powerful tools for identifying opioid misuse. This qualitative study of Veterans Affairs primary care physicians demonstrated enthusiasm for using prescription drug monitoring programs to enhance existing efforts to curb the opioid epidemic. A WebM&M commentary highlighted the utility of prescription drug monitoring programs in the hospital.
Thorpe JM, Thorpe CT, Gellad WF, et al. Ann Intern Med. 2017;166:157-163.
Prior research suggests that polypharmacy in patients with dementia may increase the risk of functional decline. This retrospective cohort study found that veterans with dementia who sought care from both within the Department of Veterans Affairs (VA) and from other health systems were more likely to receive prescriptions for potentially unsafe medications than those who sought care only within the VA system.
Payne TH, Hines LE, Chan RC, et al. J Am Med Inform Assoc. 2015;22:1243-50.
Clinical decision support alerts can help identify potential drug–drug interactions, but they can also contribute to alert fatigue. This commentary provides recommendations to inform the design of decision support to address drug–drug interactions. The authors suggest that improvement strategies focus on standardizing terminology and visual cues.
Spina JR, Glassman PA, Simon B, et al. Med Care. 2011;49:904-10.
In contrast to most hospitals and clinics, the Veterans Affairs (VA) health care system has had a fully electronic health record with computerized provider order entry for several years. In this survey, VA physicians generally had positive impressions of the system, with nearly 90% feeling the system improved drug safety and nearly half reporting that serious drug interaction warnings were "very useful." However, the accuracy of drug–drug interaction and allergy warnings within this system are partially dependent upon clinicians manually entering medications prescribed by non-VA providers. As more than one quarter of respondents admitted to not always entering this data, this study highlights the importance of medication reconciliation in establishing accurate medication lists in the ambulatory care setting.