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.

Search All Content

Clear all filter(s)

Displaying 1 - 20 of 330 Results

Hospital-Acquired Diabetic Ketoacidosis.

Save to Library

WebM&M Case February 1, 2023

This WebM&M highlights two cases of hospital-acquired diabetic ketoacidosis (DKA) in patients with type 1 diabetes. The commentary discusses the role of the inpatient glycemic team to assist with diabetes management, the importance of medication reconciliation in the emergency department (ED) for high-risk patients on insulin, and strategies to empower patients and caregivers to speak up about medication safety.

Scaling-up a pharmacist-led information technology intervention (PINCER) to reduce hazardous prescribing in general practices: multiple interrupted time series study.

Save to Library

Rodgers S, Taylor AC, Roberts SA, et al. PLoS Med. 2022;19:e1004133.

Previous research found that a pharmacist-led information technology intervention (PINCER) reduced dangerous prescribing (i.e., medication monitoring and drug-disease errors) among a subset of primary care practices in the United Kingdom (UK). This longitudinal analysis examined the impact of the PINCER intervention after implementation across a large proportion of general practices in one region in the UK. Researchers found the PINCER intervention decreased dangerous prescribing by 17% and 15% at 6-month and 12-month follow-ups, particularly among dangerous prescribing related to gastrointestinal bleeding.

Accuracy of spinal anesthesia drug concentrations in mixtures prepared by anesthetists.

Save to Library

Heesen M, Steuer C, Wiedemeier P, et al. J Patient Saf. 2022;18:e1226-e1230.

Anesthesia medications prepared in the operating room are vulnerable to errors at all stages of medication administration, including preparation and dilution. In this study, anesthesiologists were asked to prepare the mixture of three drugs used for spinal anesthesia for cesarean section. Results show deviation from the expected concentration and variability between providers. The authors recommend all medications be prepared in the hospital pharmacy or purchased pre-mixed from the manufacturer to prevent these errors.

Detectability of medication errors with a STOPP/START-based medication review in older people prior to a potentially preventable drug-related hospital admission.

Save to Library

Sallevelt BTGM, Egberts TCG, Huibers CJA, et al. Drug Saf. 2022;45:1501-1516.

Adverse events, such as medication errors, are a major cause of hospital admissions. This retrospective study of a subset of OPERAM intervention patients who were readmitted with a potentially preventable drug-related admission (DRA) examined whether use of STOPP/START criteria during in-hospital medication review can identify medication errors prior to a potentially preventable DRA. Researchers found that medication errors identified at readmission could not be addressed by prior in-hospital medication reviews because the medication error occurred after the in-hospital review or because recommended medication regimen changes were not provided or not implemented.

Preventing errors when preparing and administering medications via enteral feeding tubes.

Save to Library

ISMP Medication Safety Alert! Acute care edition. November 17, 2022;27(23).

Enteral feeding tube medication delivery presents safety challenges that can cause harm. This article highlights problems with feed tube medication administration. It shares improvement recommendations that include best practice adherence, standardization, monitoring, and patient engagement.

Interdisciplinary collaboration across secondary and primary care to improve medication safety in the elderly (The IMMENSE study) - a randomized controlled trial.

Save to Library

Johansen JS, Halvorsen KH, Svendsen K, et al. BMC Health Serv Res. 2022;22:1290.

Reducing unplanned hospital readmissions is a priority patient safety focus, and numerous interventions with hospital pharmacists have been developed. In this study, hospitalized adults aged 70 years and older were randomized to receive standard care or the IMMENSE intervention. The IMprove MEdicatioN Safety in the Elderly (IMMENSE) intervention is based on the integrated medicine management (IMM) model and consists of five steps, including medication reconciliation, patient counseling, and communication with the patient’s primary care provider. There was no significant difference in emergency department visits or readmissions between control and intervention within 12 months of the index hospital visit.

Criteria for the selection of paediatric patients susceptible to reconciliation error.

Save to Library

Iturgoyen Fuentes DP, Meneses Mangas C, Cuervas Mons Vendrell M. Eur J Hosp Pharm. 2022;Epub Sep 30.

Medication reconciliation at hospital admission has reduced medication errors, but less is known about the pediatric population, particularly which patients may benefit most from reconciliation. This retrospective study of pediatric patients who experienced at least one medication reconciliation error found children older than 5 years, taking 4 or more medications, or with neurological or onco-hematological conditions were at increased risk of errors. Prioritization of these populations may improve the effectiveness of medication reconciliation.

Understanding factors that could influence patient acceptability of the use of the PINCER intervention in primary care: a qualitative exploration using the Theoretical Framework of Acceptability.

Save to Library

Laing L, Salema N-E, Jeffries M, et al. PLoS ONE. 2022;17:e0275633.

Previous research found that the pharmacist-led IT-based intervention to reduce clinically important medication errors (PINCER) can reduce prescription and medication monitoring errors. This qualitative study explored patients’ perceived acceptability of the PINCER intervention in primary care. Overall perceptions were positive, but participants noted that PINCER acceptability can be improved through enhanced patient-pharmacist relationships, consistent delivery of PINCER-related care, and synchronization of medication reviews with prescription renewals.

Correlation between the number of patient-reported adverse events, adverse drug events, and quality of life in older patients: an observational study.

Save to Library

Beerlage-Davids CJ, Ponjee GHM, Vanhommerig JW, et al. Int J Clin Pharm. 2022;44:1434-1441.

Older adults taking multiple medications are at increased risk for adverse drug events following hospital discharge. In this study, patients were contacted two weeks after hospital discharge to evaluate adverse events, adverse drug events, and health-related quality of life (HRQoL). There was a weak but significant correlation between patient-reported adverse events and HRQoL, but not patient-reported adverse drug events.

What is the evidence that a pharmacy team working in an acute or emergency medicine department improves outcomes for patients: a systematic review.

Save to Library

Punj E, Collins A, Agravedi N, et al. Pharmacol Res Perspect. 2022;10:e01007.

Pharmacists play an important role in preventing medication errors. This systematic review identified 17 studies showing that pharmacy teams working in acute or emergency medicine departments can reduce medication errors through medication reconciliation.

Effect of pharmacist email alerts on concurrent prescribing of opioids and benzodiazepines by prescribers and primary care managers: a randomized clinical trial.

Save to Library

Sacarny A, Safran E, Steffel M, et al. JAMA Health Forum. 2022;3:e223378.

Concurrent prescribing of opioids and benzodiazepines can put patients at increased risk of overdose. This randomized study found that pharmacist email alerts to clinicians caring for patients recently co-prescribed opioids and benzodiazepines did not reduce concurrent prescribing of these medications.

Survey results from pharmacists provide support to enhance the organizational response to codes.

Save to Library

ISMP Medication Safety Alert! Acute care edition. October 6, 2022;27(20):1-5.

Patient resuscitation is a complex, distinct, team activity that can be prone to error. Pharmacists involved in codes reported concerns including errors with high-alert medications and communication gaps. Improvement recommendations focused on preparation for, actions during and post code phrases which included standardizing the practice of including pharmacists in codes, simulation, and regular debriefing.

ASHP National Survey of Pharmacy Practice in Hospital Settings: clinical services and workforce-2021.

Save to Library

Schneider PJ, Pedersen CA, Ganio MC, et al. Am J Health Syst Pharm. 2022;79:1531-1550.

Pharmacists play a critical role in ensuring patient safety in both inpatient and outpatient settings. This article describes results from the 2021 American Society of Health-System Pharmacists national survey regarding inpatient pharmacy practice. Findings suggest that more pharmacists have prescribing authority and are increasingly recognized for their role in personalized drug therapy, but nearly three-quarters of respondents reported concerns about pharmacy staffing shortages.

Economics of Medication Safety. Improving Medication Safety Through Collective, Real-time Learning.

Save to Library

de Bienassis K, Esmail L, Lopert R, Klazinga N for the Organisation for Economic Co-operation and Development. Paris, France: OECD Publishing; 2022. OECD Health Working Papers, No. 147.

The global effect of harm associated with preventable drug errors is substantial. This report discusses the human and financial impact of medication errors in a variety of countries, prescribing process improvement, established efforts to enhance medicine use safety, and avenues for national medication safety achievement.

Impact of medication reviews on potentially inappropriate medications and associated costs among older women in aged care.

Save to Library

Thiruchelvam K, Byles J, Hasan SS, et al. Res Social Adm Pharm. 2022;18:3758-3765.

Potentially inappropriate medications (PIMs) are common among older adults living in residential care facilities. This study examined the impact of the Australian Residential Medication Management Review (RMMR) service (a patient-centered medication review program) on PIM prescribing among older women living in residential aged care facilities. Researchers identified no evidence of an association between the medication review program and use of PIMs in the following year.

Review of medication error sources associated with inpatient subcutaneous insulin: recommendations for safe and cost-effective dispensing practices.

Save to Library

McKay C, Schenkat D, Murphy K, et al. Hosp Pharm. 2022;57:689-696.

Insulin is a high-alert medication due to heightened risk for serious patient harm if administered incorrectly. This review presents types of common errors (e.g., wrong patient, cross-contamination), pros and cons of potential dispensing strategies, and the impact of organizational factors (e.g., workflows, cost) on safe dispensing. Additionally, the authors make recommendations for dispensing, taking organization factors into account.

The effect of structured medication review followed by face-to-face feedback to prescribers on adverse drug events recognition and prevention in older inpatients - a multicenter interrupted time series study.

Save to Library

Klopotowska JE, Kuks PFM, Wierenga PC, et al. BMC Geriatr. 2022;22:505.

Adverse drug events (ADE) are common and preventable. In this study, hospital pharmacists met face-to-face with prescribing residents to review medications ordered for older adult inpatients. Preventable and unrecognized ADE decreased following implementation. The most common preventable ADE both before and after implementation occurred during the prescribing stage.

Effect of a pharmacy-based centralized intravenous admixture service on the prevalence of medication errors: a before-and-after study.

Save to Library

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.

Challenges of Diabetes Management and Medication Reconciliation

Save to Library

WebM&M Case August 5, 2022

This WebM&M highlights two cases where home diabetes medications were not reviewed during medication reconciliation and the preventable harm that could have occurred. The commentary discusses the importance of medication reconciliation, how to compile the ‘best possible medication history’, and how pharmacy staff roles and responsibilities can reduce medication errors.

Influence of a general practice pharmacist on medication management for patients at risk of medicine-related harm: a qualitative evaluation.

Save to Library

Jordan M, Young-Whitford M, Mullan J, et al. Aust J Gen Pract. 2022;51:521-528.

Interventions such as deprescribing, pharmacist involvement, and medication reconciliation are used to reduce polypharmacy and use of high-risk medications such as opioids. In this study, a pharmacist was embedded in general practice to support medication management of high-risk patients. This study presents perspectives of the pharmacists, general practitioners, practice personnel, patients, and carers who participated in the program.

The PSNet Collection: All Content

Search All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

The PSNet Collection: All Content

Search All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Case

Continue as a Guest

Continue Logged In

Submit Your Case

Continue as a Guest

Already have a PSNet

Account?

New Users