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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 - 15 of 15 Results
Watterson TL, Steege LM, Mott DA, et al. Jt Comm J Qual Patient Saf. 2023;49:485-493.
Occupational fatigue (e.g., stress, physical fatigue) can have deleterious effects on patients, staff, and health systems. This article describes a conceptual framework to better understand the factors contributing to occupational fatigue and downstream implications (e.g., poor patient safety, employee burnout, lower retention, and higher turnover).
White A, Fulda KG, Blythe R, et al. Expert Opin Drug Saf. 2022;21:1357-1364.
Community-based pharmacists have a critical role in ensuring medication safety in community settings. In this narrative review, the authors explored how collaboration between community-based pharmacists and primary care providers can improve medication safety. The most common collaboration strategy was medication review. The authors identified barriers to collaboration from both the primary care provider and pharmacist perspectives.
Watterson TL, Stone JA, Gilson A, et al. BMC Med Inform Decis Mak. 2022;22:50.
… BMC Med Inform Decis Mak … The CancelRx system is a health information technology-based intervention intended … data from the electronic health record (EHR) system of a midwestern academic health system, researchers found that … for controlled substances. … Watterson TL, Stone JA, Gilson A, et al. Impact of CancelRx on …
Watterson TL, Stone JA, Brown RL, et al. J Am Med Inform Assoc. 2021;28:1526-1533.
… study, the implementation of the CancelRx system led to a significant, sustained increase in successful medication … EHR and pharmacy dispensing software. … Watterson TL, Stone JA, Brown R, et al. CancelRx: a health IT tool to reduce medication discrepancies in the …
Watterson TL, Look KA, Steege LM, et al. Res Social Adm Pharm. 2021;17:1282-1287.
Fatigue has been linked to safety-related outcomes among many types of healthcare providers and settings. Using exploratory factor analysis, this study found physical and mental fatigue were the primary drivers of occupational fatigue in pharmacists. To increase safety, organizational interventions should strive to prevent burnout among pharmacists.
Perspective on Safety October 1, 2018
… efforts, evidence suggests that medication errors occur at a rate of 1.7%–22%.( 2-4 ) Of these errors, 6.5% are … [go to PubMed] 4. Kessler DO, Arteaga G, Ching K, et al. Interns' success with clinical procedures in … NJ: Pearson Prentice Hall; 2004. ISBN: 0131229176. 12. Odukoya O, Chui MA. e-Prescribing: characterisation of …
This piece reviews unique characteristics of community pharmacies that can affect medication safety and spotlights the need for further research examining medication errors in community settings.
Aboneh EA, Stone JA, Lester CA, et al. J Patient Saf. 2020;16:e18-e24.
A culture of safety is vital to identifying, addressing, and preventing adverse events. Researchers delivered AHRQ's Community Pharmacy Survey on Patient Safety Culture to 445 Wisconsin pharmacists. Independent and clinic-based pharmacists reported a more robust safety culture compared to national chain pharmacists, as did pharmacists more familiar with their patients' care.
Abebe E, Stone JA, Lester CA, et al. J Patient Saf. 2021;17:405-411.
Handoffs present a significant patient safety hazard across multiple health care settings. Interruptions and distractions, which can interfere with handoff communication, are prevalent in pharmacy environments. This cross-sectional survey of community pharmacies found that virtually none of the pharmacists had received training in how to hand off information. A significant proportion of responses indicated that pharmacy information technology systems do not support handoff communication. Respondents reported that handoffs are frequently inadequate or inaccurate. The authors conclude that interventions are needed to enhance the quality of handoff communication in community pharmacy settings to prevent dispensing errors.
Aboneh EA, Look KA, Stone JA, et al. BMJ Qual Saf. 2016;25:355-63.
The Agency for Healthcare Research and Quality has developed safety culture surveys for multiple health care settings. Researchers distributed the survey to community pharmacies and found its validity to be inadequate for use in this environment. This suggests that instruments used in other settings will require significant adaptation to accurately measure patient safety in pharmacies.
Odukoya OK, Stone JA, Chui MA. Res Social Adm Pharm. 2014;10:837-852.
The handwritten prescription pad is vanishing from clinical practice, replaced by the proliferation of e-prescribing. There are many advantages to this technology, but prescribing errors still occur at alarming rates. This study explored the approaches community pharmacists and technicians utilize to detect and manage e-prescription errors.
Odukoya OK, Stone JA, Chui MA. Int J Med Inform. 2014;83:427-37.
This direct observation study found that various medication errors related to electronic prescribing occur in community pharmacies. Contributing factors included poor inter-operability between pharmacy and clinic systems, inadequate technology usability, and data entry errors. This finding underscores the growing safety concerns associated with medication prescribing in ambulatory care.
Chui MA, Stone JA. Res Social Adm Pharm. 2014;10:195-203.
This qualitative study used interviews with community pharmacists to characterize the types of latent errors that can contribute to problems with handoffs in care. Since the handoff process was not standardized, pharmacists reported encountering both information overload and a lack of accurate information when giving and receiving handoffs.