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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 - 8 of 8 Results
Brunetti L, Santell JP, Hicks RW. Jt Comm J Qual Patient Saf. 2007;33:576-83.
Avoiding use of unclear or misleading abbreviations is a key step in preventing medication prescribing errors, and the Joint Commission mandates avoiding specific abbreviations as one of its National Patient Safety Goals. This study analyzed Medmarx data from 2004 to 2006 to determine the prevalence and impact of errors related to abbreviations. Despite dissemination of the Joint Commission's “do not use” abbreviation list, errors involving these abbreviations occurred more than 18,000 times during the study period, although few patients were harmed as a result.
Santell JP. Jt Comm J Qual Patient Saf. 2006;32:225-9.
Medication reconciliation represents an active effort of hospitals across the country to comply with recent additions to JCAHO's National Patient Safety Goals. Using data captured from USP's Medmarx program, this study discusses the errors that resulted after implementing a medication reconciliation process. Based on analysis of more than 2000 reconciliation-related errors, the author presents the distribution of errors by category (eg, potential error, intercepted error), types of errors (eg, improper dose, wrong drug, wrong time), and leading causes and contributing factors. The author also provides case examples for reconciliation errors at admission, transfer of care, and discharge. A past study also discussed practical strategies for implementing medication reconciliation processes.
Santell JP, Cousins DD. Jt Comm J Qual Patient Saf. 2005;31:649-54.
The authors use data from United States Pharmacopeia Medication Errors Reporting Program to illustrate look-alike/sound-alike errors and provide strategies to minimize their occurrence.
Santell JP, Cousins DD. The Joint Commission Journal on Quality and Patient Safety. 2016;31.
This study analyzed US Pharmacopeia's MEDMARX error-reporting database to describe characteristics of medication errors resulting from wrong administration techniques. The authors discuss the severity of errors captured and their location of origin, in addition to the most frequent contributing factors, which included performance deficit and failure to follow a protocol. Drawing from more than 7200 wrong administration technique errors, a number of true case examples are provided to illustrate the nature and scope of the problem. The authors conclude with a series of recommendations focused on greater training in administration techniques (eg, infusion pumps and dispensing devices) as well as education on a number of high-risk medications implicated in the findings.