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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 - 7 of 7 Results
Tong EY, Roman C, Mitra B, et al. J Clin Pharm Ther. 2016;41:414-8.
Medication discrepancies during hospital admission are common and can lead to preventable harm. This study examined the impact of having a pharmacist review medical charts of patients with complex medication regimens who were admitted to a general medical or emergency short-stay unit. The authors found that partnering medical staff with a pharmacist to review patients' admission medications in the chart significantly decreased inpatient medication errors.
Overhage JM, Gandhi TK, Hope C, et al. J Patient Saf. 2016;12:69-74.
Adverse drug events (ADEs) are a common source of patient harm in the ambulatory setting. A substantial proportion of ADEs are caused by preventable errors in medication prescribing or monitoring. The introduction of computerized provider order entry (CPOE) has been shown to reduce the rate of medical errors in the inpatient setting. This before–after study examined rates of ADEs in primary care practices that implemented a CPOE system in Boston and Indianapolis. At baseline, the potential ADE rate was more than seven-fold greater in Indianapolis compared to Boston. Following CPOE implementation, this rate decreased by 56% in Indianapolis but increased by 104% in Boston, and there was no change overall in preventable ADEs. A recent PSNet annual perspective reviewed the relationship and current evidence linking CPOE and patient safety.
Gandhi TK, Seger AC, Overhage M, et al. J Patient Saf. 2010;6:91-6.
Adverse drug events (ADEs) are common in ambulatory care. One classic study estimated the incidence of medication errors in outpatients at 27 per 100 patients over a 4-week period, higher than in hospitalized patients. However, ADEs may be difficult to identify in routine practice, as patients are not monitored as closely as in the inpatient setting. This study screened electronic medical records for evidence of ADEs using several different algorithms, and identified one ADE for every seven patient-years, most of which were not considered preventable. The highest yield screening algorithms were triggers that identified patients with abnormal lab values in combination with high-risk medications. An outpatient medication error due to a pharmacy dispensing error is discussed in an AHRQ WebM&M commentary.