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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 - 11 of 11 Results
Smith HS, Lesar TS. The journal of pain : official journal of the American Pain Society. 2011;12:29-40.
This analysis of analgesic prescribing near misses found that pediatric patients were most vulnerable to prescribing errors, and clinicians most frequently committed errors when prescribing medications that can be given by multiple routes of administration (i.e., intravenously and orally).
Frush KS, Hohenhaus SM eds. Clin Pediatr Emerg Med. 2006;7(4):213-283.
This special issue provides 11 articles on various aspects of ensuring safety in pediatric emergency care, including the use of rapid response teams and family involvement in care.
Lesar TS. Hosp Pharm. 2010;41:1053-1066.
Error in medication prescribing is a well-described problem in the hospital setting. This study sought to further characterize prescribing errors by determining the incidence of one specific type of error—errors in the route of administration. These errors were common, most frequently involving prescribing for the wrong route (eg, orally instead of intravenously), and cardiovascular drugs were most often implicated. The author provides suggestions for means of preventing these errors. A prior study by Lesar was one of the first to characterize the incidence of medication error in a teaching hospital setting, and he discusses the implications of error in the route of administration in a WebM&M commentary.
Hoff T, Pohl H, Bartfield J. J Organ Behav. 2006;27.
This AHRQ–funded study directly observed residents and attendings in the medical intensive care unit and trauma surgery services at an academic medical center with the goal of examining responses to errors and near misses. The authors analyzed the positive and negative aspects of specific features of the physician work culture, including the "aloofness" of attending physicians, the emphasis on avoiding "surprises" in discussing clinical information, and "pimping" of residents by attendings. Although multiple errors and near misses were observed, these were generally not used as learning opportunities, as has been found in prior research. Specific techniques that encourage a learning culture, such as providing feedback and encouraging inquiry, were rarely used in response to errors.

J Org Behavior. 2006;27(7):809-1029.

… 2006;27(7):809-1029. … R. … DM … AN … DC … N. … AL … TJ … H. … J. … R. … MK … KM … MM … T. … EJ … IM … AC … AS … MA … JP … JF … CS … M. … JA … BJ … J. … Ramanujam … Rousseau … Garman … Leach … …
Lesar TS, Briceland LL, Delcoure K, et al. JAMA. 1990;263:2329-34.
This study analyzed nearly 290,000 medication orders during a 1-year study period to determine the rates and risk factors for prescribing errors. Results indicated an overall error rate of 3.13 errors per 1000 orders written, with the greatest rate seen between noon and 4 pm and among first-year residents. Additional data presented include classes of medication involved in errors, types of errors detected, and frequency of errors by specialty service. The authors conclude that medication errors pose a significant safety risk in teaching hospitals and that system interventions, such as appropriate monitoring of prescribing habits and educational training programs, must be emphasized.
Lesar TS, Lomaestro BM, Pohl H. Arch Intern Med. 1997;157:1569-76.
This study examined more than 11,000 medication prescribing errors in order to understand the most common types and offer potential prevention strategies. Staff pharmacists detected, recorded, and evaluated each prescribing error and categorized them for further analysis. Findings include a marked increase in the number of errors from 1987 to 1995, including increases in the rate of errors per order per admission. The most common type of error involved dosing. The authors conclude by suggesting a number of strategies, such as the use of information technology and the availability of pharmacists, to counter the perceived growth of medication prescribing errors in the hospital setting.
WebM&M Case November 1, 2003
An unclear verbal order leads to administration of the wrong drug.