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.
Mulac A, Mathiesen L, Taxis K, et al. BMJ Qual Saf. 2021;30:1021-1030.
Barcode medication administration (BCMA) is a mechanism to prevent adverse medication events, but unintended consequences have also been reported when BCMA is not used appropriately. Researchers observed nurses administering medications and identified task-related, organizational, technological, environmental, and nurse-related BCMA policy deviations. Researchers provide several strategies for hospitals wishing to implement or improve BCMA systems.
Campmans Z, van Rhijn A, Dull RM, et al. PLoS One. 2018;13:e0197469.
Dispensing errors are a common source of preventable adverse events in community pharmacies. Dutch investigators evaluated the effectiveness of an electronic system in reducing drug name confusion among similar medications. Users found the system was helpful for preventing dispensing errors and did not feel it contributed substantially to alert fatigue.
van der Veen W, van den Bemt PMLA, Wouters H, et al. J Am Med Inform Assoc. 2018;25:385-392.
Workarounds occur frequently in health care and can compromise patient safety. In this prospective study, researchers observed 5793 medication administrations to 1230 inpatients in Dutch hospitals using barcode-assisted medication administration (BCMA). Workarounds occurred in about two-thirds of medication administrations. They found a significant association between workarounds and medication administration errors. The most frequently observed medication administration errors included omissions, administration of drugs not actually ordered, and dosing errors. The authors suggest that BMCA merits further evaluation to ensure that implementation of this technology promotes safety effectively. A past PSNet perspective discussed workarounds on the front line of health care.
Schwappach DLB, Taxis K, Pfeiffer Y. BMC Health Serv Res. 2018;18:123.
Medication errors are common and particularly dangerous when they involve chemotherapy. Investigators surveyed Swiss oncology nurses about double-checking medications before administration, a widely practiced strategy. Most nurses endorsed double-checking as an effective safety tool, despite the fact that double-checking promotes workflow interruptions, is labor intensive, and is less effective than automated barcode scanning.
van Welie S, Wijma L, Beerden T, et al. BMJ Open. 2016;6:e012286.
Not all pill-form medications can be safely crushed to administer to patients who have difficulty swallowing. In this before and after intervention study in a nursing home, adding warning symbols and educating staff about crushing medications led to a decrease in pill-crushing errors. The authors conclude that education and warnings enhanced this aspect of medication safety.
Schwappach DLB, Pfeiffer Y, Taxis K. BMJ Open. 2016;6.
Chemotherapy medications can cause severe patient harm if incorrectly dosed or administered. This cross-sectional survey of oncology nurses revealed that most chemotherapy double-checking is conducted jointly rather than independently. Of note, many nurses reported being interrupted to engage in a double-check.
Nguyen H-T, Pham H-T, Vo D-K, et al. BMJ Qual Saf. 2014;23:319-24.
An educational program that included lectures, ward-based teaching sessions, and protocols significantly decreased the rate of intravenous medication errors in an intensive care unit in Vietnam. However, clinically significant errors still occurred in nearly half of all medication administrations (down from 64% pre-intervention).
van Doormaal J, Rommers MK, Kosterink JGW, et al. Qual Saf Health Care. 2010;19:e26.
This study describes the development of decision support algorithms designed to prevent prescribing errors within a computerized provider order entry system. The decision support system was developed and tested in comparison to errors identified by a trained pharmacist.