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.
Hicks RW, Sikirica V, Nelson W, et al. Am J Health Syst Pharm. 2008;65:429-40.
The use of patient-controlled analgesia (PCA) is an important method to treat pain, but concerns about its safety and device selection have been raised. This study examined nearly 10,000 PCA-related medication errors submitted to MEDMARX, a database that tracks medication information from participating hospitals. Investigators discovered that patient harm was associated with 6.5% of the errors, and the errors overall were reported across all phases of the medication process. The most common errors were related to improper dosage or quantity. An AHRQ WebM&M commentary discusses a case of a PCA overdose and the mechanisms to promote its safe use.
Zhan C, Smith SR, Keyes MA, et al. Jt Comm J Qual Patient Saf. 2008;34:36-45.
Warfarin therapy is frequently associated with adverse drug events. Past efforts to identify potential prevention strategies have focused on using specific indicators or triggers to detect such events. This study examined more than 9000 errors in warfarin use submitted voluntarily through MEDMARX, a database that tracks medication information from participating hospitals. Investigators discovered that inpatient warfarin-related errors occurred most frequently during transcription/documentation and administration, while outpatient errors occurred most frequently during prescribing and dispensing. Using warfarin data as an example, the authors discuss the utility of voluntary error reporting systems and outline the limitations in their use.
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.
This study examined data from a voluntary medication error reporting system (Medmarx) to determine the incidence of harmful pediatric medication errors, the classes of medications frequently associated with error, and the types of errors that occurred. Harmful errors were defined as errors that resulted in temporary or permanent harm to the patient or required immediate intervention to avoid harm. Opioid analgesics, antimicrobials, and antidiabetic agents were most commonly associated with harmful medication errors, collectively accounting for 23.5% of the errors reported. The major type of error was administration at an incorrect dose or quantity (especially for opioid analgesics), followed by omission errors. These findings are similar to those of a previous study. The authors review the systems factors contributing to common medication errors and suggest strategies for error prevention.
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.
Zhan C, Hicks RW, Blanchette CM, et al. Am J Health Syst Pharm. 2006;63:353-8.
The investigators from the Agency for Healthcare Research and Quality (AHRQ) and United States Pharmacopeia (USP) compared MedMarx reports from facilities using computerized prescriber order entry (CPOE) with those utilizing conventional methods of ordering.
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.