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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 - 5 of 5 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).
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.
WebM&M Case November 1, 2003
An unclear verbal order leads to administration of the wrong drug.