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.
Feather C, Appelbaum N, Darzi A, et al. BMJ Qual Saf. 2023;32:357–368.
Requiring a prescriber to include an indication for a medication can reduce the risk of wrong-patient orders and improve antimicrobial and opioid stewardship. This review identified 21 studies describing interventions to encourage prescribers to include indications for medications. In addition to patient safety benefits, several risks and drawbacks were uncovered, such as potential loss of patient privacy or alert fatigue.
Kelly D, Koay A, Mineva G, et al. Public Health. 2022;214:50-60.
Natural disasters and other public health emergencies (PHE), such as the COVID-19 pandemic, can dramatically change the delivery of healthcare. This scoping review identified considerable research examining the relationship between public health emergencies and disruptions to personal medication practices (e.g., self-altering medication regimens, access barriers, changing prescribing providers) and subsequent medication-related harm.
Sutherland A, Jones MD, Howlett M, et al. Drug Saf. 2022;45:881-889.
Intravenous (IV) medication smart pumps can improve medication administration, but usability issues can compromise safety. This article outlines strategic recommendations regarding the implementation of smart pump technology to improve patient safety. Recommendations include standardization of infusion concentrations, improving drug libraries using a human-centered approach, and increasing stakeholder engagement.
Jones MD, Clarke J, Feather C, et al. Ann Pharmacother. 2021;55:1333-1340.
Medication errors during pediatric resuscitation are common. Using video recordings of simulated pediatric resuscitations, the researchers explored deviations in care related to the delivery of intravenous medicine. Findings suggest that deviations play a crucial role in intravenous medication administration errors, and deviations were more likely to occur during the use of an online injectable medicine guideline.
In 2017, the World Health Organization (WHO) introduced the third Global Patient Safety Challenge, Medication Without Harm. Interviews, focus groups, and document analysis were conducted at four UK hospitals to evaluate how they were addressing the domains and priority areas laid out in the WHO’s Patient Safety Challenge. Although all areas were addressed, additional focus is needed on patient and public involvement, transitions of care, and polypharmacy.
Jones MD, McGrogan A, Raynor DK, et al. BMJ Qual Saf. 2021;2021:17-26.
This study compared the frequency of intravenous (IV) medication errors using the current National Health Service Injectable Medicines Guide (IMG) versus revised IMG-based user-testing, which included such revisions as provision of equations and tables to support rate calculations. Findings indicate that user-tested guidelines led to fewer medication errors, less time to prepare and administer IV medications, and increased staff confidence.
Furniss D, Dean Franklin B, Blandford A. Health Inform J. 2020;26:576-591.
The authors conducted a sociotechnical investigation to describe the implementation of a closed-loop documentation system linked with smart pumps for intravenous infusion administration in one ICU. These types of closed-loop systems automate steps in the documentation of medication administration. In this case, the smart pumps were ‘mapped’ to an electronic prescribing and administration system. As a result, nurses do not need to manually enter these data after administration.
Härkänen M, Paananen J, Murrells T, et al. BMC Health Serv Res. 2019;19:791.
This retrospective study used text mining to analyze the free text descriptions in 72,390 medication administration incident reports in the National Reporting and Learning System in England and Wales to identify terms most frequently associated with risk that might otherwise remain buried within other non-relevant text. The authors identified the most common medications described in free text (insulin, antibiotics, paracetamol and morphine) and presented the most common free text terms associated with these medications. Results indicate that checking patient allergies and medication doses, especially for intravenous and transdermal medications, should be a focus of efforts to increase medication administration safety.
Garfield S, Furniss D, Husson F, et al. BMJ Qual Saf. 2020;29:764-773.
This mixed-methods study of patients, caregivers and healthcare professionals explores how patient-held medication lists (such as paper medication lists, medication diaries, or apps) can support patient safety. Patient-held lists can improve medication safety by improving the accuracy of medication reconciliation, identifying potential drug interactions, and facilitating communication.
Appelbaum N, Clarke J, Feather C, et al. BMJ Open. 2019;9:e032686.
While medication errors during paediatric resuscitation are considered common, little information about the processes that contribute to them has been gathered. This prospective observational study in a large English teaching hospital describes the incidence, nature and severity of medication errors made by 15 teams, each comprised of two doctors and two nurses, during simulated paediatric resuscitations. Clinically significant errors were made in 11 of the 15 cases, most due to discrepancies in drug ordering, preparation and administration. The authors recommend additional research into new approaches to protecting patients in paediatric emergency settings.
Blandford A, Dykes PC, Franklin BD, et al. Drug Saf. 2019;42:1157-1165.
Intravenous medication infusions are an important target for safety interventions. Many infused medications, such as opioids and chemotherapy, require vigilant adherence to protocol to prevent harm. Technical solutions to infusion errors such as computerized provider order entry, barcode medication administration, and smart infusion pumps have been implemented with some success. Investigators compared infusion errors in the United States, where all three technical interventions are common, to the United Kingdom, where those technical interventions are rare. Minor errors were common in each country, but only 0.8% of infusions placed patients at serious risk of harm. Although the details of errors in both countries differed in detail, rates of error and harm were similar. A WebM&M commentary described a chemotherapy infusion error that caused renal failure.
Puaar SJ, Franklin BD. BMJ Qual Saf. 2018;27:529-538.
Computerized provider order entry (CPOE) has vastly improved medication safety when compared to handwritten orders. However, even with CPOE, medication ordering errors are common. This qualitative study used a human factors approach to characterize electronic prescribing errors, which were primarily due to CPOE system design, organizational implementation decisions, and individual prescribing behaviors. A PSNet perspective assessed lessons learned about electronic health record safety.
Lyons I, Furniss D, Blandford A, et al. BMJ Qual Saf. 2018;27:892-901.
Errors and discrepancies in intravenous infusions were common in this study performed at two English hospitals, but only a small proportion of errors led to patient harm. The use of smart pumps did not appear to protect against errors.
Parand A, Faiella G, Franklin BD, et al. Ergonomics. 2018;61:104-121.
Informal caregivers can make errors in administering medications to patients in home settings. This human factors analysis identified multiple vulnerabilities, including incorrect dosing, storage, timing, and failure to discontinue medications as instructed. The authors note an overall lack of support and communication for caregiver-administered medications in home and community settings.
Parand A, Garfield S, Vincent CA, et al. PLoS One. 2016;11:e0167204.
Medication administration errors have been studied primarily in the hospital environment. Less is known about the types of errors that may occur in the home setting and the role caregivers play in this context. This narrative systematic review found caregiver medication administration error rates ranging from 1.9% to 33% of all medications administered, highlighting a potential threat to patient safety.
Car LT, Papachristou N, Gallagher J, et al. BMC Fam Pract. 2016;17:160.
Medication errors remain a significant source of patient harm. Although many studies have focused on the hospital setting, less is known about ambulatory medication safety. In this study, primary care physicians were asked to identify three significant problems and solutions regarding medication errors in the outpatient setting. Investigators used an innovative approach to rank the problems and solutions described by the 113 clinician respondents in the study. The top three problems identified included incomplete medication reconciliation during a transition in care, insufficient education provided to patients on their medications, and inadequate discharge summaries. Standardizing discharge summaries, decreasing unnecessary prescribing, and avoiding polypharmacy were the three highest ranked solutions. A previous PSNet perspective discussed safety in ambulatory care.