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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 - 20 of 22 Results
McDonald EG, Wu PE, Rashidi B, et al. JAMA Intern Med. 2022;182:265-273.
Deprescribing is one intervention to reduce the risk of adverse drug events, particularly in older adults and people taking five or more medications. In this cluster randomized trial, older adults (≥65 years) taking at least five medications at hospital admission were randomly assigned to intervention (personalized reports of deprescribing opportunities) or control. Despite an increase in deprescribing in both groups, there was no difference in adverse drug events or adverse drug withdrawal events.
Kurteva S, Abrahamowicz M, Gomes T, et al. JAMA Netw Open. 2021;4:e218782.
Using administrative data and patient interviews, this study sought to estimate opioid-related adverse events in adults discharged from one Canadian hospital. Among patients who filled at least one opioid prescription in the 90 days following hospital discharge, approximately 16% experienced an opioid-related emergency department visit, hospital readmission, or death. Longer duration of use and higher daily dose were associated with increased risk of adverse events. Results from this study can inform policies and strategies to limit opioid prescription dose and duration.  
Kurteva S, Habib B, Moraga T, et al. Value Health. 2021;24:147-157.
Harms related to prescription opioid use are an ongoing patient safety challenge. Based on data from one hospital between 2014 and 2016, this cohort study found that nearly 50% of hospitalized patients were discharged with an opioid prescription, and 80% of those prescriptions were among patients discharged from a surgical unit. Opioid-related medication errors were more common in handwritten discharge prescriptions compared to electronic prescriptions; electronic prescriptions were associated with a 69% lower risk of opioid-related medication errors.
Weir DL, Motulsky A, Abrahamowicz M, et al. Health Serv Res. 2020.
This study examined the effect of medication regimen changes at hospital discharge on adherence and adverse events among older adults. At 30-days post-discharge, nearly half of patients were nonadherent to at least one medication change, 26% visited the emergency department, 6% were readmitted to the hospital, and 0.5% died. Patients who were non-adherent to all medication changes had a 35% higher risk of adverse events within 30-days post-discharge compared to those were adherent to all changes.
Tamblyn R, Abrahamowicz M, Buckeridge DL, et al. JAMA Netw Open. 2019;2:e1910756.
Medication reconciliation aims to prevent adverse events after hospital discharge. In this cluster randomized trial, researchers evaluated the impact of an electronic medication reconciliation intervention involving automatic integration of community drug data and found that this process reduced medication discrepancies but did not reduce adverse events. 
McDonald EG, Wu PE, Rashidi B, et al. J Am Geriatr Soc. 2019;67:1843-1850.
This pre–post study compared patients who received medication reconciliation that was usual care at the time of hospital discharge to patients in the intervention arm who had decision support for deprescribing. Although the intervention did lead to more discontinuation of potentially inappropriate medications, there was no difference in adverse drug events between groups. The authors suggest larger studies to elucidate the potential to address medication safety using deprescribing decision support.
Martin P, Tamblyn R, Benedetti A, et al. JAMA. 2018;320:1889-1898.
This randomized controlled trial tested a pharmacist-led educational intervention at community pharmacies. Intervention patients received a brochure about potentially inappropriate medications. Discontinuation of potentially harmful medications increased among older adults compared to usual pharmacy care, suggesting that community pharmacies can play a significant role in medication safety.
Eguale T, Buckeridge DL, Verma A, et al. JAMA Intern Med. 2016;176:55-63.
Prescribing medications for indications that are not approved by the Food and Drug Administration—so-called off-label prescribing—is common. Although it is invariably well-intentioned, this population-based study demonstrates that off-label prescribing is a risk factor for medication errors. The study used the electronic medical record in Quebec that required physicians to enter the reason for prescribing or discontinuing medications to analyze the frequency of off-label prescribing and adverse events associated with this practice. Off-label prescribing was associated with a higher adverse drug event risk, especially when there was no convincing scientific indication for the unapproved use (which was the case in more than 80% of off-label prescriptions). The accompanying editorial notes that the FDA is under pressure to relax restrictions on marketing of drugs for off-label purposes and raises the concern that eliminating such restrictions could expose more patients to adverse events.
Ramjaun A, Sudarshan M, Patakfalvi L, et al. BMC Med Educ. 2015;15:33.
This systematic review aggregated studies that described education initiatives targeted at improving trainees' performance in medication reconciliation. Only seven studies were identified between 1980 and 2013, and none of the described interventions were the same. The authors suggest a combination of didactic, role-playing, and experiential learning sessions as a promising method for educating students about effective medication reconciliation practices.
Tamblyn R, Poissant L, Huang A, et al. J Am Med Inform Assoc. 2014;21:391-8.
A cornerstone of the medication reconciliation process is assembling the best possible medication history—the gold standard list of a patient's prescription and over-the-counter medications. This cohort study, conducted in an emergency department (ED) in Quebec, compared the medication history obtained by ED staff with the gold standard list of dispensed medications from their community pharmacy. The overall concordance between the two medication lists was poor, and most concerningly, more than 75% of patients had at least one medication noted in their pharmacy list that was not known to the ED. These errors of omission occurred most frequently for medications that were prescribed episodically (i.e., antibiotics) or on an as-needed basis (i.e., pain medications). The development of health information exchanges that give hospital providers direct access to pharmacy records could prevent such errors. A serious medication error due to a problem with medication reconciliation is described an AHRQ WebM&M commentary.
Auger C, Forster AJ, Oake N, et al. BMJ Qual Saf. 2013;22:306-16.
Medication errors are one of the most common types of preventable adverse events in ambulatory care, but detecting them is challenging because, unlike hospitalized patients, ambulatory patients are not regularly monitored between visits. Telephone interactive voice response systems (IVRS), which place automated phone calls to patients, have been investigated as a means of detecting adverse events after discharge. This study reports on the feasibility of using IVRS to detect adverse drug events after patients received a new prescription from their primary care physician. The authors identified several limitations: the system only reached 70% of patients despite multiple events, and elderly patients in particular had more technical difficulty with the calls and were less likely to complete them successfully. Further refinement is needed before automated mechanisms can be used to reliably detect outpatient safety problems.
McKibbon A, Lokker C, Handler S, et al. J Am Med Inform Assoc. 2012;19:22-30.
This systematic review identified 87 randomized controlled trials assessing the effect of information technology on various aspects of medication safety, including studies of computerized provider order entry. Although processes of care consistently improved, few studies demonstrated improvement in clinical outcomes.
Tamblyn R, Huang A, Taylor L, et al. J Am Med Inform Assoc. 2008;15:430-8.
Physicians were provided with a computerized decision support system that alerted them to potential adverse drug events. In one arm of the trial, the number and type of alerts could be customized by the physician. However, neither method resulted in a reduction in prescribing problems, partly because physicians ignored most alerts.
Tamblyn R, Abrahamowicz M, Dauphinee D, et al. JAMA. 2007;298:993-1001.
Poor physician-patient communication has been implicated as a factor in malpractice lawsuits. This Canadian study sought to characterize the effect of communication skills at the individual physician level, by linking scores on a standardized clinical skills examination to complaints filed by patients. Lower communication scores were significantly associated with future patient complaints, especially complaints relating specifically to poor communication. A prior commentary discussed ways of identifying problem physicians.