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.
Supply chain vulnerabilities can lead to equipment and drug shortages which can result in adverse events; the COVID-19 pandemic only exacerbated these problems. This review explains what makes the healthcare supply chain vulnerable and suggests potential solutions.
Derrong Lin I, Hertig JB. Hosp Pharm. 2022;57:323-328.
The COVID-19 pandemic necessitated urgent changes in all clinical settings including community and hospital pharmacies. This commentary describes global threats to patient safety (rapidly changing clinical evidence, counterfeit medications, drug shortages) and strategies pharmacy leaders can implement to maintain patient safety.
Moureaud C, Hertig JB, Dong Y, et al. Health Policy (New York). 2021;125:1421-1429.
Based on survey responses from 1,002 participants, this study evaluated how social media users assess, interact and engage with information related to the illegal sales of prescription medicines. Findings suggest that individuals generally perceive online pharmacies and social media platforms to be safe and respondents are confident in their ability to acquire legitimate medicines. The authors note that this false confidence has the potential to lead to patient harm given the prevalence of counterfeit and substandard medication available on these platforms.
Frontline and organizational leadership are key to implementing and sustaining safety improvement efforts. This commentary describes management principles that can prepare individuals as leaders in implementing a medication safety program, including skills in team-building, communication, tracking project progress, and encouraging innovation.
Parenteral nutrition (PN) can result in patient harm if prepared or administered improperly. Recent shortages of PN ingredients have forced pharmacies to deviate from guidelines for safe PN preparation, but this study found that the incidence of errors has not increased.
Implementation of barcode-assisted medication administration was associated with an 80% reduction in medication administration errors in an urban emergency department.
An elderly woman presented to the emergency department following a hip fracture. Although the patient's medication bottles were used to generate a medication list, one of the dosages was transcribed incorrectly. Because the patient then received four times her regular dose, her surgery was delayed due to cardiac side effects.
Kowiatek JG, Weber RJ, Skledar S, et al. Jt Comm J Qual Patient Saf. 2006;32:309-17.
… Commission journal on quality and patient safety … Jt Comm J Qual Patient Saf … This medication safety study describes a … in similar implementation strategies. … Kowiatek JG; Weber RJ; Skledar SJ; Frank S; DeVita M. …