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.
Powis M, Dara C, Macedo A, et al. BMJ Open Quality. 2023;12:e002211.
Medication reconciliation can help providers identify potential safety issues during medication administration. Based on interviews with stakeholders, this study examined medication reconciliation practices across Canadian cancer centers. Although a high proportion of the centers had a process for collecting best possible medication history (BPMH, 81%), implementation of a complete medication reconciliation process was uncommon. Stakeholders identified several barriers to implementation, including lack of resources and a lack of electronic health record interoperability across institutions, systems, and community pharmacies.
Roberts TJ, Sellars MC, Sands JM, et al. JCO Oncol Pract. 2022;18:833-839.
Missed diagnosis of infectious diseases can have serious consequences for patient safety. This article describes a delayed diagnosis of disseminated tuberculosis in a patient with lung cancer and discusses the how cognitive biases and systems failures contributed to the diagnostic error.
Admitted to the oncology service for chemotherapy treatment, a woman with leukemia was noted to be neutropenic on hospital day 6. She had some abdominal discomfort and had not had a bowel movement for 2 days. The overnight physician ordered a suppository without realizing that the patient was neutropenic and immunosuppressed. Unaware that suppositories are contraindicated in neutropenic patients, the nurse administered the suppository.
Mack JW, Jacobson J, Frank D, et al. Jt Comm J Qual Patient Saf. 2017;43:498-507.
Previous research has established that patient complaints can shed light on patient safety concerns. This analysis of 266 patient complaints in cancer care found that more than 40% were interpersonal in nature, whereas 11% were related to quality and safety. The authors suggest ongoing, systematic analysis of patient complaints in order to identify suboptimal care.
This systematic review of quality and safety practices for oral chemotherapy found that telephone calls from nurses identified adverse medication events and supported adherence. Technology-enabled approaches such as text messaging, interactive voice response, and video-observed therapy have not been effective to date.
… of standardizing the process. … Case & Commentary—Part 1 … A 48-year-old man with a history of metastatic penile cancer … solutions alone cannot overcome process failures. … Joseph O. Jacobson, MD, MSc … Chief Quality Officer, Dana … [go to PubMed] 5. Walsh KE, Dodd KS, Seetharaman K, et al. Medication errors among adults and children with …
Riechelmann RP, Tannock IF, Wang L, et al. J Natl Cancer Inst. 2007;99:592-600.
Medication safety efforts continue to focus on minimizing drug interactions. Furthermore, an aging population and greater use of chronic medications may increase the risk of such events. This study surveyed more than 400 cancer patients and discovered that more than 25% of them were at risk for a potential drug interaction. Most cases involved non-cancer agents such as warfarin and antihypertensives. In a small number of cases, patients received duplicate prescriptions. While the authors discuss the role of clinical decision support systems in preventing these events, their findings noted only potential drug interactions and not true adverse events. A similar study reported on potential drug interactions in hospitalized cancer patients.