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Patient Safety Network

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 - 9 of 9 Results
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    • Serious adverse drug events reported to the FDA: analysis of the FDA Adverse Event Reporting System 2006–2014 database.
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    • Sonawane KB, Cheng N, Hansen RA. J Manag Care Spec Pharm. 2018;24:682-690.
    This retrospective study reviewed serious and fatal adverse drug events (ADEs) reported to the Food and Drug Administration between 2006 and 2014. Over the 9-year study period, the number of serious ADEs reported doubled and a small number of medications accounted for a significant number of serious and fatal ADEs.
    Association of household opioid availability and prescription opioid initiation among household members.
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    • Seamans MJ, Carey TS, Westreich DJ, et al. JAMA Intern Med. 2018;178:102-109.
    … … JAMA Intern Med … Opioids are high-risk medications and a significant source of patient harm . Although prior … else, it remains uncertain whether individuals living in a household with a patient receiving prescription opioids are more likely to …
    Anticoagulant medication errors in nursing homes: characteristics, causes, outcomes, and association with patient harm.
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    • Desai RJ, Williams CE, Greene SB, et al. J Healthc Risk Manag. 2013;33:33-43.
    … medication errors . The state of North Carolina maintains a mandatory medication error reporting system for all nursing … is generally poor . An AHRQ WebM&M commentary discusses a preventable error due to inadequate monitoring of the anticoagulant warfarin at a nursing home, and an AHRQ WebM&M perspective explores the …
    Patterns in nursing home medication errors: disproportionality analysis as a novel method to identify quality improvement opportunities.
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    • Hansen RA, Cornell PY, Ryan PB, et al. Pharmacoepidemiol Drug Saf. 2010;19:1087-94.
    This study applied a novel analytic tool to identify rates and patterns of medication error reporting. For example, warfarin was disproportionately co-reported with communication errors just as oxycodone and morphine were with name confusion.
    Repeat medication errors in nursing homes: contributing factors and their association with patient harm.
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    • Crespin DJ, Modi A, Wei D, et al. Am J Geriatr Pharmacother. 2010;8:258-70.
    This study found that 37% of medication errors were repeated one or more times in nursing home settings, with wrong dosage and wrong administration as the most frequent causes. While the absolute harm rates were small, repeat errors were twice as likely to be harmful to patients compared to non-repeated ones.
    Medication errors during patient transitions into nursing homes: characteristics and association with patient harm.
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    • Desai R, Williams CE, Greene SB, et al. Am J Geriatr Pharmacother. 2011;9:413-22.
    … emerging safety priority. Medication safety and fostering a safety culture  are previously identified needs, but greater attention to ensure safer care transitions is a targeted goal. This study analyzed medication errors … 30,000 individual medication errors reported, 11% involved a care transition. Notably, the transition-related errors …
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