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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 223 Results
Patient Safety Primer May 30, 2023
Anyone can find it challenging to understand medical terms, and millions of Americans have trouble understanding and acting upon health information. The mismatch between individuals' health literacy skills and the complexity of health information and health care tasks involved in managing health has implications on patient safety.
Jeffries M, Salema N-E, Laing L, et al. BMJ Open. 2023;13:e068798.
Clinical decision support (CDS) systems were developed to support safe medication ordering, alerting prescribers to potential unsafe interactions such as drug-drug, drug-allergy, and dosing errors. This study uses a sociotechnical framework to understand the relationship between primary care prescribers’ safety work and CDS. Prescribers described the usefulness of CDS but also noted alert fatigue.

Patel J. PM Healthcare Journal. Spring 2023(4):5-18.

Language discordance is known to degrade medication safety. The article discusses an examination of English pharmacists’ reactions and responses to language barriers with patients. The results highlight the need for improved training and support for pharmacists to effectively dispense medications and counsel patients with whom they don’t share a common language.
Baffoe JO, Moczygemba LR, Brown CM. J Am Pharm Assoc (2003). 2023;63:518-528.
Minoritized and vulnerable people often experience delays in care due to systemic biases. This survey study examined the association between perceived discrimination at community pharmacies and foregoing or delaying picking up medications. Participants reported discrimination based on race, age, sexual orientation, ethnicity, income, and prescription insurance; those participants were more likely to delay picking up their medications. There was no association with discrimination and foregoing medications.

Horsham, PA; Institute for Safe Medication Practices: April 2023.

Community pharmacies are common providers of medication delivery that harbor process weaknesses affecting safety. This guidance shares evidence-based steps to address problems such as wrong patient errors and lack of consistent barcode system use in the community setting.
Lewis NJW, Marwitz KK, Gaither CA, et al. Jt Comm J Qual Patient Saf. 2023;49:280-284.
Community pharmacies face unique challenges in ensuring patient safety. This commentary summarizes research on prescribing errors in community pharmacies and how a culture of safety in community pharmacies can drive improvements in prescribing safety.
Perspective on Safety March 29, 2023

In the past several decades, technological advances have opened new possibilities for improving patient safety. Using technology to digitize healthcare processes has the potential to increase standardization and efficiency of clinical workflows and to reduce errors and cost across all healthcare settings.1 However, if technological approaches are designed or implemented poorly, the burden on clinicians can increase. For example, overburdened clinicians can experience alert fatigue and fail to respond to notifications. This can lead to more medical errors.

In the past several decades, technological advances have opened new possibilities for improving patient safety. Using technology to digitize healthcare processes has the potential to increase standardization and efficiency of clinical workflows and to reduce errors and cost across all healthcare settings.1 However, if technological approaches are designed or implemented poorly, the burden on clinicians can increase. For example, overburdened clinicians can experience alert fatigue and fail to respond to notifications. This can lead to more medical errors.

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.

Ledlie S, Gomes T, Dolovich L, et al. Explor Res Clin Soc Pharm. 2023;9:100218.
Mandatory error reporting systems can help identify types, causes, and solutions to medication-related errors. More than 30,000 medication-related incidents were reported by community pharmacists to the Assurance and Improvement in Medication (AIMS) Program in Canada. Event type, severity, medication class, and method of detection are described. Only 60% of pharmacies submitted at least one report, indicating compliance with and participation in the AIMS Program remains low.
Snoswell CL, De Guzman KR, Barras M. Intern Med J. 2023;53:95-103.
Community pharmacists play an important role in ensuring patient safety. This retrospective analysis of 18 outpatient pharmacy clinics evaluated pharmacist recommendations and impacts on medication-related safety. Researchers indicated that outpatient pharmacists were effective in resolving 82% of medication-related problems; 18% of these involved high-risk recommendations, such as medication interactions.
White A, Fulda KG, Blythe R, et al. Expert Opin Drug Saf. 2022;21:1357-1364.
Community-based pharmacists have a critical role in ensuring medication safety in community settings. In this narrative review, the authors explored how collaboration between community-based pharmacists and primary care providers can improve medication safety. The most common collaboration strategy was medication review. The authors identified barriers to collaboration from both the primary care provider and pharmacist perspectives.
Kelly D, Koay A, Mineva G, et al. Public Health. 2022;214:50-60.
Natural disasters and other public health emergencies (PHE), such as the COVID-19 pandemic, can dramatically change the delivery of healthcare. This scoping review identified considerable research examining the relationship between public health emergencies and disruptions to personal medication practices (e.g., self-altering medication regimens, access barriers, changing prescribing providers) and subsequent medication-related harm.
Clark J, Fera T, Fortier CR, et al. Am J Health Syst Pharm. 2022;79:2279-2306.
Drug diversion is a system issue that has the potential to disrupt patient access to safe, reliable medications and result in harm. These guidelines offer a structured approach for organizations to develop and implement drug diversion prevention efforts. The strategies submitted focus on foundational, organizational, and individual prevention actions that target risk points across the medication use process such as storage, prescribing, and waste disposal.
Saran AK, Holden NA, Garrison SR. BJGP Open. 2022;6:BJGPO.2022.0001.
Tablet-splitting may introduce patient safety risks, such as unpredictable dosing. This systematic review and qualitative synthesis did not identify substantive evidence to support tablet-splitting concerns, with the exception of sustained-release tablets and use by older adults who may struggle to split tablets due to physical limitations.

Kaplan A. NBC News. October 27, 2022. 

Suboptimal working conditions are a known contributor to errors in retail pharmacies. This news article discusses how one major pharmacy chain will adjust their staff quality metrics to eliminate timing as a performance measure in the interest of reducing pharmacist and staff burnout and fulfilment errors.
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.
Wong J, Lee S-Y, Sarkar U, et al. Am J Health Syst Pharm. 2022;79:2230-2243.
Medication errors in ambulatory care settings represent an ongoing patient safety challenge. This study characterizes ambulatory care adverse drug events reported to a large patient safety organization between May 2012 and October 2018. Anticoagulants, antibiotics, hypoglycemics, and opioids were the most commonly involved medication classes. Contributing factors included prescribing errors, failure to review clinical contraindications or drug-drug interactions, and lack of patient education or communication.
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.
Rockville, MD: Agency for Healthcare Research and Quality; July 2018.
The AHRQ Surveys on Patient Safety Culture™ (SOPS®) Community Pharmacy Survey and accompanying toolkit were developed to collect opinions of community pharmacy staff on the safety culture at their pharmacies.