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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 20 Results
Gilmartin-Thomas JF-M, Smith F, Wolfe R, et al. Int J Nurs Stud. 2017;72:15-23.
This prospective, direct-observation study examined medication administration accuracy of medications dispensed by nurses and caregivers in long-term care facilities. Investigators compared medication administration from original medication packaging to administration from multicompartment medication devices. The team observed nearly 2500 doses. When medications were dispensed from original packaging, the medication administration error rate was 9%. When multicompartment devices were used, the medication administration error rate was 3%. This difference persisted in settings where both original packaging and multicompartment medication devices were used. This study adds to the evidence about how literacy-friendly health systems can enhance medication safety.
Rostami P, Power M, Harrison A, et al. Int J Qual Health Care. 2017;29:301-309.
The NHS Safety Thermometer was developed by the National Health Service to facilitate staff participation in measuring patient harm in various care environments. This commentary describes the development, implementation, and evaluation of a Medication Safety Thermometer focused on collecting data associated with medication reconciliation, allergy status, medication omission, and harm related to high-alert medications.
Franklin BD, Reynolds M, Sadler S, et al. BMJ Qual Saf. 2014;23:629-38.
This study of medication dispensing errors at community pharmacies found that electronic transmission of prescriptions resulted in increased omission of the medication indication, but that other error types did not change. These findings suggest that electronic prescribing alone is not sufficient to address outpatient dispensing errors.
Meeks DW, Takian A, Sittig DF, et al. J Am Med Inform Assoc. 2014;21:e28-e34.
Electronic health record (EHR) implementation can be associated with both risks and improvements in safety. This study sought to characterize the positive and negative safety implications of EHR implementation and ongoing use by analyzing interview data from a 30-month evaluation of EHR implementation at 12 sites in the United Kingdom's National Health Service. The study demonstrates how eight specific human–technological factors in a sociotechnical model (people, workflow and communication, internal organizational features, external rules and regulation, measurement and monitoring, hardware and software, clinical content, human–computer interface) come into play in moving health care organizations through three phases of technology implementation. Safety hazards may be introduced in early phases of EHR implementation phases, and inappropriate use of technology as implementation progresses can also result in risks. When EHR use has stabilized, the technology can be used to promote safety.
McLeod MC, Barber N, Franklin BD. BMJ Qual Saf. 2013;22:278-89.
Errors in medication administration are common and are generally considered to account for a significant proportion of all medication errors. However, this systematic review identifies an underlying flaw inherent in studies of medication administration errors: variations in the methods used to measure errors can result in widely differing estimates of error rates. For example, only 6 of 16 included studies considered administration of a drug at the wrong time to be an error. As delayed drug administration is relatively common, studies that did not include such wrong-time errors may have reported spuriously low error rates. The authors provide a series of recommendations for standardizing measurement and reporting of medication administration error rates, with the goal of generating studies that can be used for comparisons between institutions and across time periods. Prior studies have also raised concern that variations in the definition of medication errors can affect measured error rates, and medication error measurement standards have been developed for medication reconciliation studies.
Benning A, Dixon-Woods M, Nwulu U, et al. BMJ. 2011;342:d199.
This study is the second phase of the United Kingdom's Safer Patients Initiative (SPI), a large-scale effort to improve patient safety through multifaceted interventions and an independent evaluation. Similar to the first phase study, this one demonstrated little added benefit of SPI on key safety outcomes in 20 hospitals, though overall safety did improve. An accompanying editorial [see link below] discusses the study findings and emphasizes the continued need to run toward science rather than away from it in evaluating quality improvement efforts.
Franklin BD, Birch S, Savage I, et al. Pharmacoepidemiol Drug Saf. 2009;18:992-9.
Four different strategies for identification of medication errors—prospective identification by pharmacists, retrospective chart review, use of a trigger tool, and voluntary reporting—each yielded a different estimate of the incidence of errors.
Shebl NA, Franklin BD, Barber N. J Patient Saf. 2009;5:86-94.
Failure mode and effect analysis (FMEA) is a widely used tool for hazard analysis. However, in this study, independent FMEA of the same process conducted by separate groups failed to reach similar conclusions regarding potential failures and their severity.
Franklin BD, O'Grady K, Donyai P, et al. Qual Saf Health Care. 2007;16:279-84.
Measures that have been proposed to reduce the incidence of medication errors target prescribing safety (e.g., computerized provider order entry) or safety in administering medications (e.g., bar coding or automated dispensing). While each of these individual measures has been shown to decrease errors, as yet few systems "close the loop" by integrating safety measures for prescribing and administering medications. Utilizing an electronic system that incorporated CPOE, automated dispensing, bar coding, and an electronic medication record, this single-institution study demonstrated a significant reduction in both prescribing errors and administration errors. However, staff time spent on medication-related tasks increased. While the study results are promising, one caveat is that the system was not used for high-risk drugs such as anticoagulants or intravenous medications.