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.
Jessurun JG, Hunfeld NGM, Van Rosmalen J, et al. Int J Qual Health Care. 2021;33:mzab142.
Reducing medication administration errors (MAEs) is an ongoing patient safety priority. This prospective study assessed the impact of automated unit dose dispensing with barcode-assisted medication administration on MAEs at one Dutch hospital. Implementation was associated with a lower probability of MAEs (particularly omission errors and wrong dose errors), but impact would likely be greater with increased compliance with barcode scanning.
Slikkerveer M, van de Plas A, Driessen JHM, et al. J Patient Saf. 2021;17:e587-e592.
Anticoagulants, such as low-molecular-weight heparin (LMWH), are known to be high-risk for adverse drug events. This cross-sectional study identified prescribing errors – primarily lack of dosage adjustment for body weight and/or renal function – among one-third of LMWH users admitted to one hospital over a five-month period.
This cross-sectional study examined how and to what extent non-dispensing pharmacists embedded in a general practice reported solving medication problems through clinical medication reviews in an elderly cohort of patients. The reviews identified 1,292 drug therapy problems, citing overtreatment most frequently (24%) followed by undertreatment (21%) errors. Integrating non-dispensing pharmacists into general practice may help identify and solve drug therapy problems in the elderly in this setting.
Ensing HT, Vervloet M, van Dooren AA, et al. Int J Clin Pharm. 2018;40:712-720.
This qualitative study found that postdischarge home visits from pharmacists focused on the details of the medication regimen rather than health beliefs and extent of medication adherence. The authors recommend an increased focus on patient engagement during these home visits.
Dreijer AR, Diepstraten J, Bukkems VE, et al. Int J Qual Health Care. 2019;31:346-352.
Despite their health benefits, anticoagulants place patients at high risk for medication-related harm. Researchers found that anticoagulants were responsible for 8.3% of medication errors documented in a Dutch national database, and that human behavior most commonly caused those errors. A WebM&M commentary elaborates upon the safety challenges of novel oral anticoagulants.
van der Veen W, van den Bemt PMLA, Wouters H, et al. J Am Med Inform Assoc. 2018;25:385-392.
Workarounds occur frequently in health care and can compromise patient safety. In this prospective study, researchers observed 5793 medication administrations to 1230 inpatients in Dutch hospitals using barcode-assisted medication administration (BCMA). Workarounds occurred in about two-thirds of medication administrations. They found a significant association between workarounds and medication administration errors. The most frequently observed medication administration errors included omissions, administration of drugs not actually ordered, and dosing errors. The authors suggest that BMCA merits further evaluation to ensure that implementation of this technology promotes safety effectively. A past PSNet perspective discussed workarounds on the front line of health care.
van de Plas A, Slikkerveer M, Hoen S, et al. BMJ Qual Improv Rep. 2017;6.
This commentary describes the results of a Six Sigma improvement project to reduce risks of parenteral medication administration errors that cause harm. Strategies tested included education, drug delivery modifications, and ensuring administration instructions were available.
Ensing HT, Koster ES, Stuijt CCM, et al. Int J Clin Pharm. 2015;37:430-4.
Patients are susceptible to various problems following hospital discharge, including medication errors. This commentary suggests that improving the transfer of patient medication history, performing home visits to follow up with patients, and collaboration between primary care and community pharmacy can help reduce adverse drug events after patients are discharged from the hospital.
Cheung K-C, van der Veen W, Bouvy ML, et al. J Am Med Inform Assoc. 2014;21:e63-70.
Numerous studies have identified unintended consequences associated with health information technology (IT) and computerized provider order entry, but most of these focused exclusively on the hospital setting. This study, which analyzed data from a national database of medication errors in the Netherlands, extends prior studies by examining medication errors related to IT in community pharmacies as well as hospitals. Overall, nearly one in six medication errors was attributable to problems with IT. Human factors engineering issues, such as poorly designed screens and displays, were at the root of a large proportion of these errors. Dr. Donald Norman, a founder of the human factors engineering field, was interviewed by AHRQ WebM&M in 2009.
Martijn L, Harmsen M, Gaal S, et al. J Eval Clin Pract. 2013;19:944-7.
Conducted in 70 primary care clinics in the Netherlands, this study found that clinicians' perceptions of safety culture bore little relationship to the actual incidence of patient safety events in their clinics.
Smits M, Huibers L, Kerssemeijer B, et al. BMC Health Serv Res. 2010;10:335.
… services research … BMC Health Serv Res … This study found a low rate of patient safety incidents involving telephone … incidents were related to failures in clinical reasoning. A past AHRQ WebM&M commentary discussed potential pitfalls in providing …