The PSNet Collection

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.

Detection of adverse drug events using an electronic trigger tool.

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Lim D, Melucci J, Rizer MK, et al. Am J Health Syst Pharm. 2016;73:S112-20.

… of the American Society of Health-System Pharmacists … Am J Health Syst Pharm … Trigger tools , which identify possible …

Using contemporary leadership skills in medication safety programs.

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Hertig JB, Hultgren KE, Weber RJ. Hosp Pharm. 2016;51:338-44.

Frontline and organizational leadership are key to implementing and sustaining safety improvement efforts. This commentary describes management principles that can prepare individuals as leaders in implementing a medication safety program, including skills in team-building, communication, tracking project progress, and encouraging innovation.

Evaluation of parenteral nutrition errors in an era of drug shortages.

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Storey MA, Weber RJ, Besco K, et al. Nutr Clin Pract. 2016;31:211-7.

Parenteral nutrition (PN) can result in patient harm if prepared or administered improperly. Recent shortages of PN ingredients have forced pharmacies to deviate from guidelines for safe PN preparation, but this study found that the incidence of errors has not increased.

Effect of barcode-assisted medication administration on emergency department medication errors.

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Bonkowski J, Carnes C, Melucci J, et al. Acad Emerg Med. 2013;20:801-6.

Implementation of barcode-assisted medication administration was associated with an 80% reduction in medication administration errors in an urban emergency department.

Improving medication administration safety in solid organ transplant patients through barcode-assisted medication administration.

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Bonkowski J, Weber RJ, Melucci J, et al. Am J Med Qual. 2014;29:236-41.

… journal of the American College of Medical Quality … Am J Med Qual … Organ transplant patients are at high risk for …

Analysis of risk factors for adverse drug events in critically ill patients.

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Kane-Gill SL, Kirisci L, Verrico MM, et al. Crit Care Med. 2012;40:823-8.

This cohort study identified patient- and drug-specific factors that increased the risk of adverse drug events in intensive care unit patients.

Medication Reconciliation Pitfalls

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WebM&M Case February 1, 2010

An elderly woman presented to the emergency department following a hip fracture. Although the patient's medication bottles were used to generate a medication list, one of the dosages was transcribed incorrectly. Because the patient then received four times her regular dose, her surgery was delayed due to cardiac side effects.

Examination of how a survey can spur culture changes using a quality improvement approach: a region-wide approach to determining a patient safety culture.

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Pringle J, Weber RJ, Rice K, et al. Am J Med Qual. 2009;24:374-84.

… journal of the American College of Medical Quality … Am J Med Qual … This study provides an example of how formal …

Medication errors resulting from computer entry by nonprescribers.

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Santell JP, Kowiatek JG, Weber RJ, et al. Am J Health Syst Pharm. 2009;66:843-53.

… of the American Society of Health-System Pharmacists … Am J Health Syst Pharm … Analysis of MEDMARX data found that …

Implementing a bar-code medication administration system.

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Weber RJ. Hosp Pharm. 2010;43:1016-1022.

… Hosp Pharm … This commentary discusses a single hospital’s experience in implementing a bar-code medication … framework, implementation steps, and lessons learned. … Weber RJ. Hosp Pharm. 2008;43:1016-1023. …

Developing a medication patient safety program — infrastructure and strategy.

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Mark SM, Weber RJ. Hosp Pharm. 2010;42:149-154.

… and collecting and analyzing error data. … Mark SM; Weber RJ. …

Adverse-drug-event rates for high-cost and high-use drugs in the intensive care unit.

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Kane-Gill SL, Rea RS, Verrico MM, et al. Am J Health Syst Pharm. 2006;63:1876-81.

… of the American Society of Health-System Pharmacists … Am J Health Syst Pharm … The researchers analyzed adverse drug …

Designing a strategy to promote safe, innovative off-label use of medications.

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Ansani N, Sirio CA, Smitherman T, et al. Am J Med Qual. 2006;21:255-261.

… Am J Med Qual … Am J Med Qual … The authors describe a strategy for …

Assessing and monitoring override medications in automated dispensing devices.

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Kowiatek JG, Weber RJ, Skledar S, et al. Jt Comm J Qual Patient Saf. 2006;32:309-17.

… Commission journal on quality and patient safety … Jt Comm J Qual Patient Saf … This medication safety study describes a … in similar implementation strategies. … Kowiatek JG; Weber RJ; Skledar SJ; Frank S; DeVita M. …

Citrate Mix-Up

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WebM&M Case May 1, 2006

A pharmacist mistakenly dispenses Polycitra instead of Bicitra, and a patient winds up with severe hyperkalemia and hyperglycemia.

Promethazine adverse events after implementation of a medication shortage interchange.

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Sheth HS, Verrico MM, Skledar S, et al. Ann Pharmacother. 2005;39:255-61.

This AHRQ-funded study looks at the possibilities of adverse drug events that can be heightened during a drug shortage. The authors concluded that age and the number of prescribed medications a patient is currently receiving can affect his or her safety in this situation.

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