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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 - 20 of 33 Results
Lambert BL, Galanter W, Liu KL, et al. BMJ Qual Saf. 2019;28:908-915.
Look-alike and sound-alike (LASA) drugs are a well-established source of medication errors that place patients at risk for adverse drug events. Prior research has shown that these medications can be automatically identified using diagnostic codes at the time of electronic prescribing. Using electronic health record data on medication orders and diagnostic claims data from a single academic medical center as well as data on medication indications, researchers developed an algorithm to identify LASA prescribing errors. Although the algorithm was able to identify LASA prescribing errors that may not have been found by other means, the positive predictive value was 12.1% and the false-positive rate was greater than 75%. The authors advocate for further research to improve specificity and sensitivity of this approach. A past WebM&M commentary discussed a case involving the mix-up of two medications with similar names.
Adelman JS, Applebaum JR, Schechter CB, et al. JAMA. 2019;321:1780-1787.
Having multiple patient records open in the electronic health record increases the potential risk of wrong-patient actions. This randomized trial tested two different electronic health record configurations: one allowed up to four patient records to be open at a time, and the other allowed only one to be open. Among the 3356 clinicians with nearly 4.5 million order sessions, there were no significant differences in wrong-patient orders. However, the investigators noted that clinicians in the multiple records group placed most orders with just one record open. A post hoc analysis determined that the rate of errors increased when orders were placed with multiple records open. A related editorial highlights the tradeoffs between safety and efficiency and argues for examining the context of the two configurations, including throughput and clinician satisfaction. A previous PSNet perspective discussed assessing and improving the safety of electronic health records.
Schroeder SR, Salomon MM, Galanter W, et al. BMJ Qual Saf. 2017;26:395-407.
Look-alike and sound-alike drug names are a concerning source of confusion and medication errors. Although drug names currently undergo tests to assess their potential for confusion prior to approval, these tests have not reliably predicted real-world error rates. This study describes the development and validation of four drug name memory and perception laboratory tests. Eighty participants completed the tests and their results were analyzed against actual errors in two large outpatient pharmacy chains. The laboratory tests performed very well, demonstrating a strong association between drug name confusion errors seen during testing and those observed in real-world experience. The authors suggest that regulators and drug companies consider using these tests prior to approval of new drug names.
Vaida AJ. J Med Toxicol. 2015;11:262-264.
Poison control centers serve as data collection points for ambulatory medication errors that result in harm. This commentary highlights how reporting programs that collect such data can collaborate and disseminate information about medication-related incidents to reduce errors and promote improvement.
Greenall J, Shastay A, Vaida AJ, et al. J Oncol Pharm Pract. 2015;21:26-35.
In 2012, more than 350 organizations from 13 countries participated in the initial Institute for Safe Medication Practices self-assessment for oncology. This study describes results from this baseline survey, which revealed key opportunities for improvements in the safe delivery of chemotherapy. For example, many institutions have still not followed best practices for the administration of vincristine. In addition, less than half of respondents had fully implemented safety processes for oral chemotherapy orders. A prior AHRQ WebM&M commentary describes a patient who inadvertently received the wrong chemotherapy regimen and explores the high risks associated with inpatient chemotherapy.
Vaida AJ, Lamis RL, Smetzer JL, et al. The Joint Commission Journal on Quality and Patient Safety. 2016;40.
In 2000, the Institute for Safe Medication Practices (ISMP) introduced the Medication Safety Self Assessment, establishing a national baseline of hospitals' efforts to improve medication safety. This study evaluated progress over the past decade by repeating this voluntary survey in 2011. Nearly a quarter of all registered hospitals in the United States participated. Overall scores improved significantly compared with those in 2000. Computerized provider order entry implementation increased from 6% to 55% of hospitals. There were also advances in patient education and communication of drug orders. One of the largest changes was an 833% increase in scores related to safety culture. Despite these developments, the survey also reveals many areas for improvement, such as accurate documentation of important patient information. A prior AHRQ WebM&M interview with Michael Cohen, president of ISMP, discussed medication safety.
Greenwald JL, Halasyamani L, Greene J, et al. J Hosp Med. 2010;5:477-85.
A National Patient Safety Goal (NPSG) since 2005, medication reconciliation involves verifying medications and dosages as well as documenting and explaining medication changes. Medication reconciliation has been notoriously difficult to accomplish in both inpatient and outpatient settings. The Joint Commission currently does not evaluate medication reconciliation in accreditation surveys. This consensus statement, endorsed by The Joint Commission and other major professional societies, calls for recasting medication reconciliation in a patient-centered, patient safety–oriented fashion. Several key steps to develop effective and usable reconciliation tools include multidisciplinary involvement with clear roles among clinicians, patient-centered measurement strategies, and rigorous study and dissemination of implementation strategies. The findings of this consensus group will be used in the revised medication reconciliation NPSG, which will be issued in 2011.
Perspective on Safety July 1, 2008
… the lesson discovered by Pasteur so many years ago. … Patrice Spath, BA, RHIT … Healthcare Quality Specialist Brown-Spath & … 4. Braithwaite J, Westbrook MT, Mallock NA, Travaglia JF, Iedema RA. …
Throughout most of his life, 19th century French chemist Louis Pasteur insisted that germs were the cause of disease, not the body. It wasn't until Pasteur was nearing the end of his life that he came to believe just the opposite. After reaching this conclusion, he declined treatment for potentially curable pneumonia, reportedly saying, "It is the soil, not the seed."(1) In other words, a germ (the seed) causes disease when our bodies (the soil) provide a hospitable environment.