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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 - 8 of 8 Results
Ojeda IM, Sánchez-Cuervo M, Candela-Toha Á, et al. Crit Care Nurs. 2023;43:30-38.
High-alert medications can cause serious patient harm if administered incorrectly. This article describes a quality improvement project to reduce medication errors involving high-alert sedative and analgesic medications in the intensive care unit (ICU) through use of protocolized and centralized smart intravenous infusion pump technology. Use of the protocolized software led to the interception of nearly 400 infusion-related programming errors.
Pueyo-López C, Sánchez-Cuervo M, Vélez-Díaz-Pallarés M, et al. J Oncol Pharm Pract. 2021;27:1588-1595.
Researchers in this study used healthcare failure mode and effect analysis (HFMEA) to identify and reduce errors during chemotherapy preparation. Nine potential failure modes were identified – wrong label, drug, dose, solvent, or volume; non-sterile preparation; incomplete control; improper packaging or labeling, and; break or spill – and the potential causes and effects. Potential approaches to reduce these failure modes include updating the Standard Operating Procedures (SOPs), implementing a bar code system, and using a weight-based control system.
Parro Martín M de los Á, Muñoz García M, Delgado Silveira E, et al. J Eval Clin Pract. 2021;27:160-166.
Researchers analyzed medication errors occurring in the trauma service of a single university hospital in Spain to inform the development and implementation of a set of measures to improve the safety of the pharmacotherapeutic process. The Multidisciplinary Hospital Safety Group proposed improvement measures that intend to involve pharmacists in medication reconciliation, increase the use of medication reconciliation in the emergency and trauma departments, and incorporate protocols and alerts into the electronic prescribing system.
Vélez-Díaz-Pallarés M, Pérez-Menéndez-Conde C, Bermejo-Vicedo T. Am J Health Syst Pharm. 2018;75:1909-1921.
Use of computerized provider order entry (CPOE) is increasingly widespread. This systematic review found that while CPOE with clinical decision support reduced certain medication errors associated with prescribing, CPOE led to the introduction of new errors.
Vélez-Díaz-Pallarés M, Díaz AMÁ, Caro TG, et al. Int J Clin Pharm. 2017;39:729-742.
Nearly all of the medication errors in a Spanish hospital's computerized provider order entry system related to human factors issues involving the interaction between clinicians and the technology itself. These included previously identified problems associated with errors in free-text fields and errors resulting from autocompletion of partially entered orders.
Cuervo S, Sanchis R, Lopez P, et al. J Clin Pharm Ther. 2015;40:550-554.
Computerized provider order entry (CPOE) has been shown to decrease some adverse drug events (ADEs), but it has also introduced medication errors across multiple settings. This study examined the incidence of ADEs in an inpatient hematology–oncology setting in three timeframes: before CPOE, immediately following implementation, and 5 years later. Although researchers found a significant reduction in ADEs, some errors persisted. These results argue for continued development of decision support to enhance prescribing, particularly in high-risk environments such as inpatient cancer treatment. A past AHRQ WebM&M interview discussed how technology can augment medication safety.
Vélez-Díaz-Pallarés M, Delgado-Silveira E, Carretero-Accame ME, et al. BMJ Qual Saf. 2013;22:42-52.
In this study, failure mode and effect analysis—a prospective risk assessment tool—successfully identified actions that led to reductions in medication errors at a Spanish university hospital.