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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 - 9 of 9 Results
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 …
Desai RJ, Williams CE, Greene SB, et al. J Healthc Risk Manag. 2013;33:33-43.
Patients in nursing homes are generally elderly, chronically ill, and take multiple medications, which places them at higher risk for medication errors. The state of North Carolina maintains a mandatory medication error reporting system for all nursing homes. This study analyzed data from this system to characterize errors due to anticoagulant drugs (which are considered high-risk medications). Errors were found to be common and harmful, often due to inadequate monitoring to ensure appropriate drug dosing. The authors recommend several potential solutions, but any interventions will likely also have to address the fact that safety culture in nursing homes 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 difficult problem of ensuring medication safety in nursing facilities.
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.
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.
Desai R, Williams CE, Greene SB, et al. Am J Geriatr Pharmacother. 2011;9:413-22.
Scrutiny over the quality of care delivered in post-acute settings is catalyzing improvement initiatives for this 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 reported by North Carolina nursing homes to describe specific errors that occurred during patient transitions to nursing homes. Of the nearly 30,000 individual medication errors reported, 11% involved a care transition. Notably, the transition-related errors were also associated with higher odds of patient harm. Contributing factors to the transition-related reports included problems with staff communication, order transcription, medication availability, and pharmacy issues. The authors highlight the opportunities for medication safety during this high-risk transition period for patients.