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.
McCarthy SE, Hogan C, Jenkins L, et al. BMJ Open Qual. 2023;12:e002270.
Debriefing after significant clinical events helps affected staff develop a shared mental model of what happened, why it happened, and how it can be prevented in the future. This paper describes development of training videos on after action reviews (AAR)s, a type of debriefing. The videos introduce AAR, show a simulated AAR debriefing, offer techniques for handing challenging situations within an AAR, and reflections on the benefits. The videos are available with the online version of the paper.
Hung A, Wang J, Moriarty F, et al. J Am Geriatr Soc. 2023;71:2023-2027.
Deprescribing is used to reduce the risk of adverse drug events resulting from polypharmacy among older adults. This article outlines several recommendations for improved cost-effectiveness analyses of deprescribing interventions to support decision makers.
Gleeson LL, Clyne B, Barlow JW, et al. Int J Pharm Pract. 2023;30:495-506.
Remote delivery of care, such as telehealth and e-prescribing, increased sharply at the beginning of the COVID-19 pandemic. This rapid review was conducted to determine the types and frequency of medication safety incidents associated with remote delivery of primary care prior to the pandemic. Fifteen articles were identified covering medication safety and e-prescribing; none of these studies associated medication safety and telehealth.
Silva B, Ožvačić Adžić Z, Vanden Bussche P, et al. Int J Environ Res Public Health. 2022;19:10515.
The COVID-19 pandemic led to dramatic changes in healthcare delivery. The multi-country PRICOV-19 study evaluated how primary care practices reorganized their day-to-day work during the pandemic and the impacts on patient safety culture. This study compared training vs. non-training primary care practices and found that training practices had a stronger safety culture during the pandemic.
Reeve J, Maden M, Hill R, et al. Health Technol Assess. 2022;26:1-148.
Deprescribing is a strategy to reduce potential harms associated with polypharmacy. This scoping review synthesized the evidence about how physicians and patients feel about deprescribing and how deprescribing can be done safely. Shared decision making was identified as an essential component for building trust in the process and for keeping it patient-centered.
Gleeson LL, Ludlow A, Wallace E, et al. Explor Res Clin Soc Pharm. 2022;6:100143.
Primary care rapidly shifted to telehealth and virtual visits at the start of the COVID-19 pandemic. This study asked general practitioners (GPs) and pharmacists in Ireland about the impact of technology (i.e., virtual visits, electronic prescribing) on medication safety since the pandemic began. Both groups identified electronic prescribing as the most significant workflow change. GPs did not perceive a change in medication safety incidents due to electronic prescribing; pharmacists reported a slight increase in incidents.
Pérez T, Moriarty F, Wallace E, et al. BMJ. 2018;363:k4524.
Elderly patients are at greater risk of experiencing adverse drug events than the adult population as a whole. Older patients are more likely to be frail, have more medical conditions, and are physiologically more sensitive to injury from certain classes of medication. Researchers examined a large cohort of Irish outpatients age 65 and older to determine the relationship between hospital discharge and potentially inappropriate medication prescribing. Approximately half of the 38,229 patients studied were prescribed a medication in contravention to the STOPP criteria. The risk of potentially inappropriate prescribing increased after hospital discharge, even when using multiple statistical techniques to control for medical complexity. An accompanying editorial delineates various vulnerabilities that predispose older patients to adverse events during the transition from hospital to home. A recent PSNet perspective discussed community pharmacists' role in promoting medication safety.
Moriarty F, Bennett K, Fahey T. Heart. 2019;105:204-209.
Combination medications are frequently used to improve adherence, but they may also contribute to medication errors. Using pharmacy claims data, researchers found that the prescribing of antihypertensive fixed-dose combination medication was associated with a greater risk of therapeutic duplication.
Reeve E, Moriarty F, Nahas R, et al. Expert Opin Drug Saf. 2017;17:39-49.
Deprescribing has been recommended as a way to reduce polypharmacy. This review examines safety concerns associated with deprescribing among older patients and offers strategies to reduce risks. The authors suggest that further research is needed to understand potential harms of deprescribing and highlight the importance of shared decision-making to improve the safety of this process.
Barry E, O'Brien K, Moriarty F, et al. BMJ Open. 2016;6:e012079.
Although certain medication classes pose increased risks to children, well-defined criteria for potentially inappropriate prescribing for pediatric patients have not been established. This study described an iterative consensus-building process which identified 12 indicators of potentially inappropriate medications for children. Future studies will test the validity of these indicators.
Clyne B, Fitzgerald C, Quinlan A, et al. J Am Geriatr Soc. 2016;64:1210-22.
Older patients are more vulnerable to adverse drug events, and a key safety strategy is to avoid prescribing high-risk medications to these patients. This systematic review found that pharmacist medication review and clinical decision support, as well as combined approaches, were modestly effective at reducing high-risk prescribing for older patients. The authors suggest that further studies are needed to identify more effective means of promoting safe prescribing for this vulnerable population.