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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 355 Results
Kramer JS, Hayley Burgess L, Warren C, et al. J Patient Saf Risk Manag. 2023;Epub Aug 27.
Obtaining a best possible medication history (BPM) is an important component of successful medication reconciliation programs. This study compared the impact of a pharmacy-led medication reconciliation program including BPMH on adverse drug events (ADEs) and complications among high-risk, complex patients across 16 hospitals. In the six months following implementation, 80,000 reconciliations were completed and nearly 40% required additional medication follow-up and/or clarification. Researchers identified a statistically significant decrease in both ADEs and complications after implementation.
Mikkelsen TH, Søndergaard J, Kjaer NK, et al. BMC Geriatr. 2023;23:477.
Older adults taking 5 or more medications daily (i.e., polypharmacy) face numerous challenges to taking them safely. In this study, patients, caregivers, and clinicians describe methods to taking medications safely, difficulties they face, and ways prescribers and pharmacists can assist patients. Medication reviews, a common strategy to ensure safe polypharmacy, were requested by patients to clear up confusion around generics, timing, limitations, and side effects.
Spinks J, Violette R, Boyle DIR, et al. Med J Aust. 2023;Epub Aug 16.
Medication safety in ambulatory care settings is an area of growing concern. This article describes ACTMed (ACTivating primary care for MEDicine safety), a cluster randomized trial set in Australia which intends to improve medication safety in primary care settings. The ACTMed intervention will use health information technology (e.g., clinical indicator algorithms), guideline-based clinical recommendations, shared decision-making, and financial incentives to reduce serious medication-related harm, medication-related hospitalizations, and death.
Kaya GK, Ustebay S, Nixon J, et al. Safety Sci. 2023;166:106260.
Voluntary incident reporting rates may be an indicator of organizational safety culture. Using different machine learning algorithms, this study found that several components of safety culture – compassionate culture, violence and harassment, and work pressure – have a significant impact on predicting incident reporting behavior.
Dunbar EG, Massey AC, Lee YL, et al. Am Surg. 2023;89:3272-3274.
Medication reconciliation is an important care process anytime a patient transitions from one care setting to another, including emergency department to hospital admission. This study sought to determine the incidence of completed medication reconciliation for admitted trauma patients and the number of identified discrepancies. Of the 89 patients included in the study, more than a quarter did not receive an admission medication reconciliation (AMR), and of those with an AMR, 48% had at least one unintended discrepancy, indicating the importance of completing medication reconciliation for all admitted trauma patients.

ISMP Medication Safety Alert! Acute care edition. July 13, 2023;(4):1-3;July 27, 2023;(5):1-5.

Risk Evaluation and Mitigation Strategy (REMS) programs help to ensure the safe use of distinct medications through communication, patient information, and implementation support. Part I of this article series examines systemic barriers to the deployment of REMS as a strategy to decrease potential for drug-related harm and medication error. Part II looks at the processes that one health system used to implement REMS.
Walsh DJ, Sahm LJ, O'Driscoll M, et al. J Geriatr Oncol. 2023;14:101540.
Older adults with cancer are typically prescribed multiple medications (i.e., polypharmacy) and are therefore at risk of adverse drug events (ADE). In this study, the medical records of older adults (those at least 70 years old) receiving cancer care who had an unplanned hospital admission were reviewed to determine if it was potentially related to an ADE. Of the hospitalized patients, more than half were potentially due to ADE at three and six months after the initial oncology visit. Including a clinical pharmacist may help reduce ADEs and hospitalizations.
Wang Y, Eldridge N, Metersky ML, et al. Circ Cardiovasc Qual Outcomes. 2023;16:e009573.
Unplanned hospital readmission and 30-day all-cause mortality rates are indicators of hospital safety. This study analyzed the association of these two indicators with in-hospital adverse events (AE) for patients admitted with heart failure. Results suggest patients with heart failure admitted to hospitals with high rates of 30-day all-cause mortality and readmission are at increased risk for in-hospital AE. The authors describe several possible explanations for these findings.
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.
Zahl-Holmstad B, Garcia BH, Johnsgård T, et al. BMJ Open Qual. 2023;12:e002239.
Designated emergency department (ED) pharmacists are increasingly used to improve the quality of medication administration in the ED. This qualitative study explored patient perceptions of medication safety before and during an ED pharmacist-led intervention (including medication reconciliation and medication review) in collaboration with ED physicians. Participants underscored the importance of trust and responsibility but noted that it was not important who carried out these medication-related tasks, but rather that the participant received the help they needed.
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.
Fisher L, Hopcroft LEM, Rodgers S, et al. BMJ Medicine. 2023;2:e000392.
Pharmacists play a critical role in medication safety. This article evaluated the impact of a pharmacist-led information technology intervention (PINCER) among a retrospective cohort of 56.8 million National Health Service (NHS) patients across 6,367 general practices between September 2019 and September 2021. Findings indicate that potentially dangerous prescribing (i.e., prescribing medications to patients without associated blood test monitoring, co-prescribing medications with adverse indications, prescribing medications to patients with certain comorbidities) was largely unaffected by the COVID-19 pandemic.
Basger BJ, Moles RJ, Chen TF. BMC Geriatr. 2023;23:183.
Potentially inappropriate medications (PIM) and polypharmacy, defined as taking 5 or more medications, can increase the risk of hospitalization and other adverse events for older adults. This article describes the implementation and success of a patient-centered medication review conducted at the time of hospital discharge. Nearly all patients followed up with their general practitioner on the pharmacist’s recommendations and approximately three-quarters were implemented. Including the patient and/or caregiver was a key component of the intervention. 
WebM&M Case April 26, 2023

This case represents a known but generally preventable complication of calcium chloride infusion, eventually necessitating surgical amputation of the patient’s left fourth (ring) finger. The commentary discusses the importance of correctly identifying IV fluids as irritants or vesicants, risks associated with the use of vesicants such as calcium chloride, and the role of early recognition of infiltration and extravasation and symptom management to minimize tissue damage and accelerate healing.

Schnipper JL, Reyes Nieva H, Yoon CS, et al. BMJ Qual Saf. 2023;32:457-469.
Implementing successful interventions to support effective medication reconciliation is an ongoing challenge. The MARQUIS2 study examined whether system- and patient-level interventions plus physician mentors can improve medication reconciliation and reduce medication discrepancies. This analysis based on patient exposure in the MARQUIS2 study found that patient receipt of a best possible medication history (BPMH) in the emergency department and medication reconciliation at admission and discharge were associated with the largest reductions in medication discrepancy rates.
Feinstein JA, Orth LE. J Pediatr. 2023;254:4-10.
Children with medical complexity (CMC) frequently take multiple medications, often from multiple prescribers. This commentary describes the particular vulnerabilities CMC face throughout the medication use cycle, along with ways for the prescriber and system to mitigate the risks of polypharmacy.
Feather C, Appelbaum N, Darzi A, et al. BMJ Qual Saf. 2023;32:357–368.
Requiring a prescriber to include an indication for a medication can reduce the risk of wrong-patient orders and improve antimicrobial and opioid stewardship. This review identified 21 studies describing interventions to encourage prescribers to include indications for medications. In addition to patient safety benefits, several risks and drawbacks were uncovered, such as potential loss of patient privacy or alert fatigue.
Patient Safety Innovation March 29, 2023

Medication reconciliation is a common strategy to improve patient safety but is complex and time consuming. Three academic medical centers developed and implemented a risk stratification tool so limited pharmacist resources could be allocated to patients with the highest likelihood of medication adverse events.

WebM&M Case March 15, 2023

This case focuses on immediate-use medication compounding in the operating room and how the process creates situations in which medication errors can occur. The commentary discusses strategies for safe perioperative compounding and the role of standardized processes, such as checklists, to ensure medication safety.

WebM&M Case March 15, 2023

The cases described in this WebM&M reflect fragmented care with lapses in coordination and communication as well as failure to appropriately address medication discrepancies. These two cases involve duplicate therapy errors, which have the potential to cause serious adverse drug events.