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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 - 7 of 7 Results

Aronson JK, Heneghan C, Ferner RE. Br J Clin Pharmacol. Epub 2023 Jul 16.

Addressing drug shortages is a patient safety priority. Part One of this review summarizes existing definitions for drug shortages and the harms that can occur due to drug shortages (e.g., medication errors, treatment delays, undertreatment). Part Two discusses trends in drug shortages, the causes of drug shortages, and potential solutions.
Nwulu U, Nirantharakumar K, Odesanya R, et al. Eur J Clin Pharmacol. 2013;69:255-9.
This retrospective review examined more than 50,000 hospital admissions using two triggers—INR level and use of naloxone (an opioid reversal drug)—to determine whether these criteria improved detection of adverse drug events.
Coleman JJ, Hemming K, Nightingale PG, et al. J R Soc Med. 2011;104:208-218.
Hard stop alerts within computerized provider order entry (CPOE) systems are intended to avert serious medication errors by preventing prescribing of contraindicated medications. This study investigated whether data from a CPOE system could be used to identify individual physicians who commit more frequent prescribing errors. However, the study found that trainee physicians who committed errors prompting hard stop alerts were not more likely to commit less serious prescribing errors, nor did they appear to ignore prescribing warnings more frequently. Although objective performance data would help identify doctors who frequently make prescribing errors, this study's results indicate that triggering of CPOE alerts is not a reliable measure.
McDowell SE, Mt-Isa S, Ashby D, et al. Qual Saf Health Care. 2010;19:341-345.
Although computerized provider order entry is being widely implemented to prevent medication errors, a significant proportion of errors are not due to incorrect prescribing, but instead occur at the drug administration stage. This study sought to estimate the error rate associated with each stage of the intravenous medication administration process and identify effective error prevention strategies. Prior research has investigated the use of smart infusion pumps, bar coding, and nursing education to prevent medication administration errors.
Brit J Clin Pharmacol. 2009;67:589-695.
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