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.
Conn R, Fox A, Carrington A, et al. Pharmaceutical Journal. 2023;310:7973.
Children are particularly vulnerable to medication errors. Weight- and age-based dosing, different medication formulations, and miscommunication with parents and caregivers contribute to errors. Data-driven education and peer feedback have been noted as effective strategies to reduce prescribing errors.
Dornan T, Lee C, Findlay-White F, et al. Med Teach. 2021;43:1419-1429.
Health profession students are required to demonstrate competence in a variety of areas related to safe patient care. This article puts forth a recommendation to move beyond core competencies to improve patient safety and clinicians’ mutual safety.
Conn RL, Kearney O, Tully MP, et al. BMJ Open. 2019;9:e028680.
This scoping review identified numerous causes for prescribing errors in pediatrics, including dosing errors related to the need for weight-based calculations, communication with children, and level of clinical experience in pediatrics. The authors suggest that further research is needed to better understand how these factors are tied to prescribing mistakes.
Conn RL, McVea S, Carrington A, et al. PLoS One. 2017;12:e0186210.
Intravenous medication administration is complex and can lead to dosing errors, especially in children. This analysis of critical incident reports related to intravenous fluid prescribing errors among children found a range of errors and underlying causes. The authors suggest that training physicians to work with nurses and pharmacists may help prevent medication errors with intravenous infusions.
Ashcroft DM, Lewis PJ, Tully MP, et al. Drug Saf. 2015;38:833-43.
Medication prescribing errors are common in hospitals, and previous research has suggested junior doctors may make the most mistakes. In this prospective study, pharmacists in 20 hospitals in the United Kingdom reviewed medication orders and prescribing errors. More than 120,000 orders were reviewed over the 7-day study period, and prescribing errors were found in 8.8% of medication orders. Doctors in their first 2 years of training were more than twice as likely to make prescribing errors compared to doctors that had completed training. However, many of these errors were minor and the rates of serious or potentially fatal errors did not differ between trainees and senior physicians, suggesting that interventions should focus on all physicians. A 2014 AHRQ PSNet Annual Perspective reviewed current trends to address patient safety in medical education.
Lewis PJ, Ashcroft DM, Dornan T, et al. Br J Clin Pharmacol. 2014;78:310-9.
Prescribing-related errors are common among junior physicians. Analyzing trainee physicians' prescribing errors using the critical incident technique, researchers identified several underlying causes, including knowledge deficits and authority gradients.