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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
de Lemos J, Loewen PS, Nagle C, et al. BMJ Open Qual. 2021;10:e001161.
Adverse drug events – many of which are preventable – are a major source of patient harm. This cross-sectional study explored the causes of preventable adverse drug events (ADEs) and how patients, families, and providers can prevent them. The study finds that the most common causes of preventable ADEs involved providers not ensuring that patients and/or family understood the medication plan or could identify symptoms of side effects. The researchers used the study findings to develop learning messages for providers, patients, and families and to implement a preventable ADE surveillance system.
Zed PJ, Black KJL, Fitzpatrick EA, et al. Pediatrics. 2015;135:435-43.
Prior research has found that adverse drug events are a common source of emergency department (ED) visits and hospital admissions in adults. This prospective observational study involved more than 2000 pediatric patients presenting to an ED at a tertiary academic medical center in Canada. Medications were directly related to the presenting chief complaint in 8% of patients, with two-thirds of these deemed preventable. The vast majority of medication-related visits were classified as causing moderate harm, but approximately 5% of cases were severe. Children with a medication-related ED visit were much more likely to be admitted to the hospital and to have a longer length of stay than children presenting to the ED with other problems. The results of this study add to a prior systematic review by the same research group, which also found that a significant proportion of adverse drug events in pediatric patients presenting to the ED were likely avoidable.
Hohl CM, Zed PJ, Brubacher JR, et al. Ann Emerg Med. 2010;55:493-502.e4.
Adverse drug events are a common cause of emergency department visits in children and adults, but it is unclear how accurately emergency physicians identify medication errors as a cause of a patient's presenting symptoms. In this study, emergency department patients were evaluated by a clinical pharmacist for a possible drug-related cause of their presentation, and the pharmacists' assessment was compared to that of the treating emergency physician. Agreement was only moderate, implying that physician diagnoses may actually underestimate the true incidence of medication error–related emergency department visits.
Samoy LJ, Zed PJ, Wilbur K, et al. Pharmacotherapy. 2006;26:1578-86.
Medication errors are common in hospitalized patients, and are a common reason for emergency room visits. This prospective, observational study examined the frequency with which medication errors resulted in the need for hospital admission. Fully one-quarter of admissions were directly related to a medication error, most frequently an adverse drug reaction or an incorrectly selected medication. This rate is much higher than a prior study performed in cardiology patients, which found a 6% incidence of medication error–related hospitalizations. As in other studies, the medications most commonly associated with errors were cardiovascular agents and antibiotics.