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.
Articles in this special issue focus on adverse drug reactions and proactive strategies to reduce risks, such as using natural language processing to detect adverse effects related to medications, engaging community pharmacists in the medication process through better connectivity to patient data, and improving the evidence base on reducing smart pump nuisance alarms.
Buckley MS, Rasmussen JR, Bikin DS, et al. Ther Adv Drug Saf. 2018;9:207-217.
This retrospective study examined the performance of trigger alerts designed to predict drug-related hazardous conditions in both ICU and non-ICU patients. The authors conclude that the alerts were not effective in identifying drug-related hazardous conditions in either setting and suggest that poorly performing alerts may contribute to alert fatigue.
Kane-Gill SL, O'Connor MF, Rothschild JM, et al. Crit Care Med. 2017;45:1481-1488.
These paired systematic reviews examined alert fatigue in the intensive care unit. The first systematic review found several strategies to reduce alerts including prioritizing alerts, developing multipart rules instead of simple alerts, and customizing commercial platforms with end-user input. The second systematic review found that alarm best practices from high reliability industries are not adhered to in intensive care unit settings.
Kane-Gill SL, Dasta JF, Buckley MS, et al. Crit Care Med. 2017;45:e877-e915.
Although technology has helped decrease medication errors, adverse drug events remain a significant source of harm. Patients in the intensive care unit (ICU) may be particularly vulnerable to medication errors due to the complex nature of their care. Prior research has shown that medication errors occur more frequently in the ICU and are more likely to cause serious patient harm or death. This clinical practice guideline highlights environmental changes and prevention strategies that can be employed to improve medication safety in the ICU. The authors also describe components of active surveillance that may augment detection of medication errors and adverse drug events. A previous WebM&M commentary discussed a case involving a serious medication error in the ICU setting.
Kane-Gill SL, Achanta A, Kellum JA, et al. World J Crit Care Med. 2016;5:204-211.
Medication administration technologies can help collect data to enhance processes and reduce medication errors. This commentary discusses how organizations are using clinical decision support systems to track problems and incorporating different data sets to prevent adverse drug events.
DiPoto JP, Buckley MS, Kane-Gill SL. Drug Saf. 2015;38:311-7.
A persistent challenge in patient safety is detecting and intervening in unsafe situations before patients are harmed. Trigger tools have been widely used in retrospective studies to identify and characterize adverse events, and this study reports on a novel use for triggers—detecting potentially harmful drug interactions during the computerized provider order entry process. Trigger alerts in a computerized provider order entry system at three hospitals (academic, community, and rural) were reviewed by a pharmacist, who then either personally made changes or contacted the prescribing physician. The triggers were developed by a multidisciplinary team involving clinicians and information technologists and were tailored to identify clinically significant medication errors. The authors found that more than 40% of the alerts required pharmacist intervention, and that over 90% of pharmacist recommendations were accepted by the prescribing physicians. Therefore, the triggers used in this study generated far fewer false-positive alerts than seen in other studies. The proliferation of false-positive warnings is a primary contributor to alert fatigue, and although this study did not directly measure this phenomenon, it is plausible that use of more tailored alerts could avert alarm fatigue.
Kane-Gill SL, Rubin EC, Smithburger PL, et al. J Pain Palliat Care Pharmacother. 2014;28:282-93.
Opioids are particularly dangerous medications that may lead to various adverse drug events including nausea, vomiting, respiratory depression, and death. This review defined the substantial economic impact of adverse events resulting from opioids, finding health care costs increased 7% to 47% for patients that experienced an opioid–related adverse event.
Buckley MS, Harinstein LM, Clark KB, et al. Ann Pharmacother. 2013;47:1599-610.
Pharmacists are increasingly leading hospital medication reconciliation programs. Pharmacists at one institution resolved as many as 3.5 medication errors per patient, nearly half of these were considered significant or serious. Although the nature of this work is time-consuming, the program saves an estimated $1.3 million per year due to averted medication errors.
Gokhman R, Seybert AL, Phrampus P, et al. Resuscitation. 2012;83:482-7.
Despite increased adoption of computerized provider order entry, medication errors are a continued problem in acute care settings, particularly in high-risk ones such as intensive care units. These concerns are perhaps greatest for patients with acute clinical deterioration who need rapid resuscitative efforts. This study evaluated medication errors during activation of medical emergency teams. While the study was performed at a single site with a limited sample size, the findings of nearly 1 in 2 doses administered in error was alarming. More than 65% of errors involved breaks in aseptic technique, while nearly half of those remaining were prescribing errors. Almost 15% of errors were classified as at least moderate in severity, underscoring the need for greater attention to medication safety in these clinical situations.
Stockwell DC, Kane-Gill SL. Crit Care Med. 2010;38:S117-25.
This study reviewed the literature on different error surveillance systems and highlights what each system—such as chart review, trigger tools, and incident reporting systems—offers to organizational improvement efforts.