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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 244 Results

Pharmacy Practice News Special Edition. December 13, 2022: 43-54.

Medication errors continue to occur despite long-standing efforts to reduce them. This article summarizes types of errors submitted to the Institute for Safe Medication Practices reporting program in 2021. The piece discusses the medications involved, recommendations for improvement, and technologies to be employed to minimize error occurrence.
Mohanna Z, Kusljic S, Jarden R. Aust Crit Care. 2022;35:466-479.
Many types of interventions, such as education, technology, and simulations, have been used to reduce medication errors in the intensive care setting. This review identified 11 studies representing six intervention types; three of the six types showed improvement (prefilled syringe, nurses’ education program, and the protocolized program logic form) while the other three demonstrated mixed results.
Fuller AEC, Guirguis LM, Sadowski CA, et al. Sr Care Pharm. 2022;37:421-447.
While barcode-assisted medication administration (BCMA) and electronic medication administration records (eMAR) technologies have reduced adverse drug events, workarounds that may contribute to medication errors have been identified for both. This study of medication administration errors was conducted in a Canadian long-term care facility following implementation of eMAR-BCMA software. During the twenty-nine-month study period, 190 medication administration errors were reported.
Passwater M, Huggins YM, Delvo Favre ED, et al. Am J Clin Pathol. 2022;158:212-215.
Wrong blood in tube (WBIT) errors are rare but can lead to complications. One hospital implemented a quality improvement project to reduce WBIT errors with electronic patient identification, manual independent dual verification, and staff education. WBIT errors were significantly reduced and sustained over six years.
Austin JM, Bane A, Gooder V, et al. J Patient Saf. 2022;18:526-530.
Use of bar code medication administration (BCMA) technology in hospitals has been shown to decrease medication errors at the time of administration. In 2016, the Leapfrog Group implemented a standard for BCMA use as part of its hospital survey. This article describes the development, testing, and subsequent refinement of the BCMA standard.
Gauthier-Wetzel HE. Comput Inform Nurs. 2022;40:382-388.
Barcode medication administration (BCMA) has been promoted as an effective method for reducing medication administration errors. In the emergency department of one Veterans Affairs Medical Center, medication error rates decreased by nearly 11% following introduction of BCMA technology. However, unsafe workarounds were also identified, which may limit the overall safety of BCMA.
Jessurun JG, Hunfeld NGM, Van Rosmalen J, et al. J Patient Saf. 2022;18:e1181-e1188.
Intravenous admixture preparation errors (IAPE) in hospitals are common and may result in harm if they reach the patient. In this before-and-after study, IAPE data were collected to evaluate the safety of a pharmacy-based centralized intravenous admixture service (CIVAS). Compared to the initial standard practice (nurse preparation on the ward), IAPE of all severity levels (i.e., potential error, no harm, harm) decreased and there were no errors in the highest severity level after implementation of CIVAS.
Smith-Love J. J Nurs Care Qual. 2022;37:327-333.
Barcode medication administration (BCMA) is one approach to reducing near-miss medication safety events. Researchers used a FOCUS (find-organize-clarify-understand-select) PDSA (plan-do-study-act) methodology to help frontline nursing staff identify gaps in care processes and root causes contributing to poor compliance with barcode medication administration.
Lichtner V, Dowding D. Stud Health Technol Inform. 2022;294:740-744.
Barcode medication administration (BCMA) processes are designed to prevent some types of medication administration errors. This article discusses how BCMA workflows support error prevention and how to identify workarounds that negate these error prevention mechanisms.
Perspective on Safety March 31, 2022

Errors in medication management and administration are major threats to patient safety. This piece explores issues with opioid and nursing-sensitive medication safety as well as medication safety in older adults. Future research directions in medication safety are also discussed.

Rajan SS, Baldwin JL, Giardina TD, et al. J Patient Saf. 2022;18:e262-e266.
Radiofrequency identification (RFID) technology has been most commonly used in perioperative settings to improve patient safety. This study explored whether RFID technology can improve process measures in laboratory settings, such as order tracking, specimen processing, and test result communication. Findings indicate that RFID-tracked orders were more likely to have completed testing process milestones and were completed more quickly.
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...
Jessurun JG, Hunfeld NGM, Van Rosmalen J, et al. Int J Qual Health Care. 2021;33:mzab142.
Reducing medication administration errors (MAEs) is an ongoing patient safety priority. This prospective study assessed the impact of automated unit dose dispensing with barcode-assisted medication administration on MAEs at one Dutch hospital. Implementation was associated with a lower probability of MAEs (particularly omission errors and wrong dose errors), but impact would likely be greater with increased compliance with barcode scanning. 
Mulac A, Hagesaether E, Granas AG. J Adv Nurs. 2022;78:224-238.
Medication dosing errors can lead to serious patient harm. This retrospective study found that the majority of dose calculation errors reported to the Norwegian Incident Reporting System involved intravenous administration such as intravenous morphine. These errors occurred due to lack of proper safeguards to intercept prescribing errors, stress, and bypassing double checks.
WebM&M Case October 27, 2021

A 78-year-old woman with macular degeneration presented for a pars plana vitrectomy (PPV) under monitored anesthesia care (MAC) with an eye block. At this particular hospital, eye cases under MAC are typically performed with an eye block by the surgeon after the anesthesiologist has administered some short-acting sedation, commonly with remifentanil. On this day, there was a shortage of premixed remifentanil and the resident – who was unfamiliar with the process of drug dilution – incorrectly diluted the remifentanil solution.

Dunbar NM, Delaney M, Murphy MF, et al. Transfusion (Paris). 2021;61:2601-2610.
Transfusion errors can have serious consequences. This study compared wrong blood in tube (WBIT) errors in 9 countries across three settings: emergency department, inpatient, and outpatient. Results show emergency department WBIT errors were significantly higher in emergency departments, and that electronic positive patient identification (ePPID) significantly reduced WBIT errors in the emergency department, but not in inpatient or outpatient wards.
Schnock KO, Biggs B, Fladger A, et al. J Patient Saf. 2021;17:e462-e468.
Hospitals have implemented radiofrequency identification (RFID) technology to improve patient safety. This systematic review of 5 studies suggests that use of RFID can lead to rapid, accurate detection of retained surgical instruments (RSIs) and reduced risk of counting errors.
Mulac A, Mathiesen L, Taxis K, et al. BMJ Qual Saf. 2021;30:1021-1030.
Barcode medication administration (BCMA) is a mechanism to prevent adverse medication events, but unintended consequences have also been reported when BCMA is not used appropriately. Researchers observed nurses administering medications and identified task-related, organizational, technological, environmental, and nurse-related BCMA policy deviations. Researchers provide several strategies for hospitals wishing to implement or improve BCMA systems.
WebM&M Case April 28, 2021

Two separate patients undergoing urogynecologic procedures were discharged from the hospital with vaginal packing unintentionally left in the vagina. Both cases are representative of the challenges of identifying and preventing retained orifice packing, the critical role of clear handoff communication, and the need for organizational cultures which encourage health care providers to communicate and collaborate with each other to optimize patient safety.