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.
This simulation study compared performance of pharmacists in preparing chemotherapy under conditions of increasing workload, as measured by the number of doses needed. Investigators found that as the volume of work increased, so did the risk of errors. This finding highlights the need to ensure working conditions promote safety.
Kaestli L-Z, Cingria L, Fonzo-Christe C, et al. Int J Clin Pharm. 2014;36:953-62.
Researchers performed prospective risk assessment using failure mode and effects analysis for medication errors following hospital discharge. This method identified more errors than traditional incident reporting, as expected given the known under-reporting in all voluntary safety reporting mechanisms studied.
Bonnabry P, Despont-Gros C, Grauser D, et al. J Am Med Inform Assoc. 2008;15:453-60.
Rapid adoption of computerized provider order entry (CPOE) systems has led to debate around their reported benefits. This study conducted a detailed quantitative analysis, following a failure mode and effect analysis (FMEA), and concluded that such analyses are necessary to guide continuous improvement efforts at ensuring CPOE systems do improve safety.
Bonnabry P, Cingria L, Ackermann M, et al. Int J Qual Health Care. 2006;18:9-16.
Using failure mode and effect analysis (FMEA), this study examined the role that pharmacy services organization and information technologies (IT) played in more than 12,000 chemotherapy treatments at a 2200-bed university hospital. Investigators performed their analyses after reengineering of the medication administration process and prior to full integration of IT solutions. Findings suggested major improvements and risk reduction resulting from the reengineering process, with centralization of pharmacy and IT implementations contributing complementary benefits. The study provides a nice example of how FMEA techniques analyze high-risk care processes while prioritizing the opportunities for necessary safety interventions.