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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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Approach to Improving Safety
Displaying 1 - 20 of 179 Results
Baimas-George MR, Ross SW, Yang H, et al. Ann Surg. 2023;278:e614-e619.
Hospital-acquired venous thromboembolism (VTE) remains a significant source of preventable patient harm. This study of 4,252 high-risk general surgery patients found that only one-third received care in compliance with VTE prophylaxis guidelines. Patients receiving guideline-compliant care experienced shorter lengths of stay (LOS), fewer blood transfusions, and decreased odds of having a VTE, emphasizing the importance of initiating VTE chemoprophylaxis in high-risk general surgery patients.
Fanikos J, Tawfik Y, Almheiri D, et al. Am J Med. 2023;136:927-936.
Anticoagulants are high-risk medications in both outpatient and inpatient settings. This study compared two time periods, both before and after implementation of anticoagulant safety programs, to assess changes in type, severity, root cause, and outcomes of adverse events in hospitalized patients. Despite numerous changes in procedures and technology, adverse events increased in the post-implementation period.
Pradeda AM, Pérez MSA, Oliveira CF, et al. Farm Hosp. 2023;47:121-126.
Medication reconciliation is used when a patient moves from one level or location of care to another, to ensure they are receiving the appropriate medications. This retrospective study reviewed completed medication reconciliations of adult patients transferring from the intensive care unit to the ward. Nearly one in five had an error requiring physician changes to the order. Of those errors, 19% were high-alert medications, most notably low-molecular-weight heparin.
Rowily AA, Jalal Z, Paudyal V. Expert Opin Drug Saf. 2023;Epub Jun 14.
Direct oral anticoagulant (DOAC) dosing is complex and can lead to medication errors. This analysis of 15,730 incident reports involving DOACs reported in the United Kingdom between 2017 and 2019 found that the majority (87.6%) were due to active failures and 2.2% resulted in moderate/severe harm or death. This PSNet WebM&M commentary discusses approaches to improving safety when prescribing DOACs.
van der Horst SFB, van Rein N, van Mens TE, et al. Thromb Res. 2023;Epub Mar 27.
Although direct-acting oral anti-coagulants (DOACs) are considered safer than warfarin, DOAC dosing is complex and can lead to medication errors. This narrative review discusses the clinical consequences of potentially inappropriate inpatient prescribing of DOACs and how pharmacists and anticoagulant stewardship programs can optimize inpatient DOAC treatment.
Baartmans MC, van Schoten SM, Smit BJ, et al. J Patient Saf. 2023;19:158-165.
Sentinel events are adverse events that result in death or severe patient harm and require a full organizational investigation to identify root causes and make recommendations to prevent recurrence. This study pooled sentinel event reports from 28 Dutch hospitals to identify common system-level contributing factors. Aggregation of system-level factors may provide more urgency in implementing recommendations than a single case at one organization.
The Joint Commission.
The National Patient Safety Goals (NPSGs) are one of the major methods by which The Joint Commission establishes standards for ensuring patient safety in all health care settings. In order to ensure health care facilities focus on preventing major sources of patient harm, The Joint Commission regularly revises the NPSGs based on their impact, cost, and effectiveness. Major focus areas include promoting surgical safety and preventing hospital-acquired infections, medication errors, inpatient suicide, and specific clinical harms such as falls and pressure ulcers. The 2023 goals, which include a goal to improve health equity, are now available.
Richie CD, Castle JT, Davis GA, et al. Angiology. 2022;73:712-715.
Hospital-acquired venous thromboembolism (VTE) continues to be a significant source of preventable patient harm. This study retrospectively examined patients admitted with VTE and found that only 15% received correct risk stratification and appropriate management and treatment. The case review found that patients were commonly incorrectly stratified, received incorrect pharmaceutical treatment, or inadequate application of mechanical prophylaxis (e.g., intermittent compression).
Keller C. Health Aff (Millwood). 2022;41:1353-1356.
Communication failures due to hierarchy and silos create opportunities for adverse medication and treatment events. This narrative essay discusses gaps in care coordination that contributed to anticoagulant medication errors. The author outlines areas for improvement such as assignment of accountability for error and commitment to the learning health system as avenues for improvement.

Washington DC; National Quality Forum and Anticoagulation Forum; 2022.

Warfarin and other anticoagulants are high-alert medications that, if errors occur in their use, can result in considerable harm. This document advocates that a stewardship approach be applied to anticoagulant therapy to reduce the risk of adverse events and discusses steps to implement and sustain a program to guide the safe, effective use of anticoagulants.
Brown A, Cavell G, Dogra N, et al. Int J Med Inform. 2022;164:104780.
Alert fatigue and subsequent overrides are known contributors to preventable adverse events particularly for high-risk drug-drug interactions. Researchers assessed prescribers’ actions following an alert for new prescriptions of Low Molecular Weight Heparins (LMWHs) to patients currently prescribed Direct Acting Anticoagulants (DOACs). More than half of the alerts were overridden but were appropriate and justified in most cases.
Curated Libraries
January 14, 2022
The medication-use process is highly complex with many steps and risk points for error, and those errors are a key target for improving safety. This Library reflects a curated selection of PSNet content focused on medication and drug errors. Included resources explore understanding harms from preventable medication use, medication safety...
Al Rowily A, Jalal Z, Price MJ, et al. Eur J Clin Pharmacol. 2022;78:623-645.
Although direct acting oral anticoagulants (DAOCs) are generally considered safer than older anticoagulants, they are still high-risk medications. This review found that between 5.3% and 37.3% of patients experienced either a prescription, administration, or dosing error. Prescribing errors constituted the majority of error types, and common causes were active failures, including wrong drug or wrong dose.
Haque H, Alrowily A, Jalal Z, et al. Int J Clin Pharm. 2021;43:1693-1704.
While direct oral anticoagulants (DOAC) are considered safer than warfarin, DOAC-related medication errors still occur. This study assesses the frequency, type, and potential causality of DOAC-related medication errors and the nature of clinical pharmacist intervention. Active, rather than latent, failures contributed to most errors.
Attia E, Fuentes A, Vassallo M, et al. Am J Health Syst Pharm. 2022;79:297-305.
Anti-coagulants are classified as high-risk medications due to their potential to cause serious patient harm if not administered correctly. This hospital created a multidisciplinary anticoagulant safety taskforce to reduce errors and improve patient safety. The article describes the implementation process, including the use of the 2017 Institute for Safe Medication Practices (ISMP) Medication Safety Self-Assessment for Antithrombotic Therapy tool.
Slikkerveer M, van de Plas A, Driessen JHM, et al. J Patient Saf. 2021;17:e587-e592.
Anticoagulants, such as low-molecular-weight heparin (LMWH), are known to be high-risk for adverse drug events. This cross-sectional study identified prescribing errors – primarily lack of dosage adjustment for body weight and/or renal function – among one-third of LMWH users admitted to one hospital over a five-month period.
Sugrue A, Sanborn D, Amin M, et al. Am J Cardiol. 2020;144:52-59.
Anticoagulants are common medications that carry the potential for serious harm if administered incorrectly. This retrospective review of 8,576 patients with atrial fibrillation who received direct oral anticoagulants identified inappropriate dosing in nearly 15% of cases, with most patients receiving an inappropriately low dose. Over one year of follow-up, the authors did not identify any significant difference in the incidence of stroke, embolism, bleeding, or ischemic attacks between patients who were inappropriately, versus appropriately, dosed.
Cattaneo D, Pasina L, Maggioni AP, et al. Drugs Aging. 2021;38:341-346.
Older adults are at increased risk of hospitalization due to COVID-19 infections. This study examined the potential severe drug-drug interactions (DDI) among hospitalized older adults taking two or more medications at admission and discharge. There was a significant increase in prescription of proton pump inhibitors and heparins from admission to discharge. Clinical decision support systems should be used to assess potential DDI with particular attention paid to the risk of bleeding complications linked to heparin-based DDIs.
Gurwitz JH, Kapoor A, Garber L, et al. JAMA Intern Med. 2021;181:610-618.
High-risk medications have the potential to cause serious patient harm if not administered correctly. In this randomized trial, a pharmacist-directed intervention (including in-home assessment by a clinical pharmacist, communication with the primary care team, and telephone follow-up) did not result in a lower rate of adverse drug events or medication errors involving high-risk drug classes during the posthospitalization period.
WebM&M Case November 25, 2020

A 60-year-old male presented to the emergency department (ED) with his partner after an episode of dizziness and syncope when exercising. An electrocardiogram demonstrated non-ST-elevation myocardial infarction abnormalities. A brain CT scan was ordered but the images were not assessed prior to initiation of anticoagulation treatment. While awaiting further testing, the patient’s heart rate slowed and a full-body CT scan demonstrated an intracranial hemorrhage. An emergent craniotomy was performed and the patient later died.