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

Personal Health Literacy

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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.

Using sociotechnical theory to understand medication safety work in primary care and prescribers' use of clinical decision support: a qualitative study.

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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.

The impact of language barriers on patient care: a pharmacy perspective.

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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.

Perceived discrimination in the community pharmacy: a cross-sectional, national survey of adults.

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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.

ISMP Targeted Medication Safety Best Practices for Community Pharmacy.

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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.

Creating a stronger culture of safety within US community pharmacies.

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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.

Technology as a Tool for Improving Patient Safety

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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.

Duplicate Therapies in Retail Pharmacy

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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.

Medication errors in community pharmacies: evaluation of a standardized safety program.

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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.

Pharmacists reducing medication risk in medical outpatient clinics: a retrospective study of 18 clinics.

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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.

Defining and enhancing collaboration between community pharmacists and primary care providers to improve medication safety.

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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.

A scoping review of non-professional medication practices and medication safety outcomes during public health emergencies.

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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.

ASHP Guidelines on Preventing Diversion of Controlled Substances.

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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.

Concerns regarding tablet splitting: a systematic review.

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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.

Predicting dispensing errors in community pharmacies: an application of the Systematic Human Error Reduction and Prediction Approach (SHERPA).

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Patient Safety Innovation November 16, 2022

Community pharmacists encounter a wide range of challenges to medication safety. This study used a novel prospective method of predicting errors and developing remedial solutions.

Walgreens will stop judging its pharmacy staffers by how fast they work.

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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.

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.

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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.

Medication adverse events in the ambulatory setting: a mixed-methods analysis.

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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.

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

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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.

Community Pharmacy Survey on Patient Safety Culture.

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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.

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