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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 216 Results
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.
Pitts SI, Yang Y, Woodroof T, et al. J Patient Saf. 2022;18:e934-e937.
CancelRx is a health information tool designed to improve communication between electronic health record (EHR) systems and pharmacy dispensing software. This study found that CancelRx implementation eliminated the sale of electronically prescribed medications after discontinuation in the EHR, compared to prior to implementation. Researchers found that CancelRx did result in the unintentional cancellation of some prescriptions and they discuss the importance of situational awareness among providers and pharmacy staff to mitigate this issue.
Gleeson LL, Ludlow A, Wallace E, et al. Explor Res Clin Soc Pharm. 2022;6:100143.
Primary care rapidly shifted to telehealth and virtual visits at the start of the COVID-19 pandemic. This study asked general practitioners (GPs) and pharmacists in Ireland about the impact of technology (i.e., virtual visits, electronic prescribing) on medication safety since the pandemic began. Both groups identified electronic prescribing as the most significant workflow change. GPs did not perceive a change in medication safety incidents due to electronic prescribing; pharmacists reported a slight increase in incidents.

ISMP Medication Safety Alert! Acute care edition. June 2, 2022;27(11):1-4.

Minimizing look-alike/sound-alike medication risk is a universal need across health care. This story highlights a primary prevention tool that lists problematic drug names. It shares strategies across the medication use process to reduce errors associated with similarly named and labeled medications such as separate storage areas and tall man lettering.
Uitvlugt EB, Heer SE, van den Bemt BJF, et al. Res Soc Admin Pharm. 2022;18:2651-2658.
Pharmacists play a critical role in medication safety during transitions of care. This multi-center study found that a transitional pharmacy care program (including teach-back, pharmacy discharge letter, home visit by community pharmacist, and medication reconciliation by both the community and hospital pharmacist) did not decrease the proportion of patients with adverse drug events (ADE) after hospital discharge. The authors discuss several possible explanations as to why the intervention did not impact ADEs and suggest that a process evaluation is needed to explore ways in which a transitional pharmacy care program could reduce ADEs.
Hall N, Bullen K, Sherwood J, et al. BMJ Open. 2022;12:e050283.
Reporting errors is a key component of improving patient safety and patient care. Primary care prescribers and community pharmacists in Northeast England were interviewed about perceived barriers and enablers to reporting medication prescribing errors, either internally or externally. Motivation, capability, and opportunity influenced reporting behaviors. 

Institute for Safe Medication Practices.

Workplace bullying and disrespectful behavior have been shown to negatively affect fall rates, medication errors, and other adverse events. The Institute for Safe Medication Practices is seeking clinician input on and experiences with disrespectful behaviors in the ambulatory care setting (e.g., community, specialty, and long-term care pharmacies, physician practices, and outpatient visits) and how organizations have been working to improve the culture of respect. 
Coates MC, Granche J, Sefcik JS, et al. Res Gerontol Nurs. 2022;15:69-75.
Older adults, especially those taking multiple medications, are at increased risk for medication self-administration (MSE) errors. Data from the National Health and Aging Trends Study (NHATS) was analyzed to ascertain if the source of the medication ­– picking up from local pharmacy, receiving the medication via mail-order pharmacy, or both ­– impacted MSE or hospitalization. Respondents receiving medications via both mail-order and pick up were more likely to report hospitalizations and medication mistakes.
Peat G, Olaniyan JO, Fylan B, et al. Res Social Adm Pharm. 2022;18:3534-3541.
The COVID-19 pandemic has impacted all aspects of healthcare delivery for both patients and health care workers. This study explored the how COVID-19-related policies and initiatives intended to improve patient safety impacted workflow, system adaptations, as well as organizational and individual resilience among community pharmacists.
Mercer K, Carter C, Burns C, et al. JMIR Hum Factors. 2021;8:e22325.
Clear communication regarding medication indications can improve patient safety. This scoping review explored how including the indication on a prescription may impact prescribing practice. Studies suggest that including the indication can help identify errors, support communication, and improve patient safety, but prescribers noted concerns about impacts on workflow and patient privacy.

Cohen M, Degnan D, McDonnell P, eds. Patient Saf. 2022;4(s1):1-45

Pharmacists play a unique role in patient safety that educational methods are shifting to address. This special issue covers several topics including strategies to reduce the susceptibility of hospitalized infants and children to medication errors, and infusing safety culture into pharmacy school curriculum.
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...