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 677 Results

Medication Mix-Up Leads to Patient Death.

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WebM&M Case November 30, 2023

An 81-year-old man was admitted to the intensive care unit (ICU) with a gastrointestinal bleed and referred for a diagnostic colonoscopy. The nurse preparing the patient for the colonoscopy mistakenly selected a jug of dialysis liquid rather than a polyethylene glycol solution commonly used to clean the colon for colonoscopy. When the barcode on the jug of dialysis liquid did not scan, the nurse called the hospital pharmacy for assistance and was provided a new barcode via a tube system.

Prevented harm and cost avoidance with pharmacist intervention while utilizing a discharge medication reconciliation tool.

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Hoffman AM, Walls JL, Prusch A, et al. Am J Health Syst Pharm. 2023;Epub Oct 9.

Hospitals must balance costs associated with pharmacist medication reconciliation (e.g., salary) with prevented harm and cost avoidance (e.g., unreimbursed expenses resulting from medication error). This study found an estimate cost avoidance of $47,000 - $231,000 during one month in one hospital. The highest-risk, highest-cost classes were insulin, antithrombotics, and opioids. In resource-limited environments, focusing on the highest-cost classes could avoid significant cost and patient harm.

Temporarily holding medication orders safely in order to prevent patient harm.

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ISMP Medication Safety Alert! Acute care edition. October 19, 2023;28(21):1-4.

Process disconnects can cause administration mistakes that lead to harm. This article discusses reasons for holding medications and how workflow issues can contribute to medication temporary stop order problems. Recommendations for improvement include examining electronic health record alerts, assigning one prescriber to oversee medication reconciliation, and instituting a policy on hold orders.

Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose.

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WebM&M Case October 31, 2023

A 2-year-old girl presented to the emergency department (ED) with joint swelling and rash following an upper respiratory infection. After receiving treatment and being discharged with a diagnosis of allergic urticaria, she returned the following day with worsening symptoms. Suspecting an allergic reaction to amoxicillin, the ED team prepared to administer methylprednisolone. However, the ED intake technician erroneously switched the patient’s height and weight in the electronic health record (EHR), resulting in an excessive dose being ordered and dispensed.

Pharmacy-led medication reconciliation is best practice.

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Tanski MC. Pharmacy Times Health Systems edition. September 2023;12(5):34-35.

Medication reconciliation should be completed at admission, discharge, and during transitions of care. This article describes the impacts of pharmacist involvement, including lower hospital readmissions and post-discharge adverse events.

RFID tags reduce restocking errors of anesthesia medications.

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Banks MA. Specialty Pharmacy Continuum. September 15, 2023.

Radiofrequency identification (RFID) devices are being used to improve processes in the operating room and prevent errors. This article examines the use of RFID tracking to build reliability into operating room anesthesia medication refiling process. The experience at one hospital found that the RFID process reduced errors, while increasing the task completion time.

Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable

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WebM&M Case September 27, 2023

A 14-year-old girl was admitted to the hospital with a new diagnosis of type 1 diabetes mellitus without ketoacidosis. Before discharge, medications intended for home use were delivered to the patient’s bedside, but the resident physician noticed a discrepancy. An insulin pen and pen needles had been ordered, but an insulin vial and extra insulin syringes were delivered. Neither the patient nor the parents had received education on how to draw up and administer insulin using a vial and syringe.

Impact of pharmacist-led admission medication reconciliation on patient outcomes in a large health system.

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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.

Development of a proactive process to harmonize policy, infusion pump library, and electronic health record entries for continuous infusions at an academic medical center.

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Christensen SM, Andrews SR, Fox ER. Am J Health Syst Pharm. 2023;80 :S119-S122.

To maximize safety benefits of smart infusion pumps, drug libraries between the pump, electronic health record (EHR) and pharmacy must be standardized. This article describes the proactive standardization between drug libraries for continuous infusions, including medication names, concentrations, and pump rates. 82 updates were required across the three libraries.

Protocolization of analgesia and sedation through smart technology in intensive care: improving patient safety.

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Ojeda IM, Sánchez-Cuervo M, Candela-Toha Á, et al. Crit Care Nurs. 2023;43:30-38.

High-alert medications can cause serious patient harm if administered incorrectly. This article describes a quality improvement project to reduce medication errors involving high-alert sedative and analgesic medications in the intensive care unit (ICU) through use of protocolized and centralized smart intravenous infusion pump technology. Use of the protocolized software led to the interception of nearly 400 infusion-related programming errors.

Drug shortages.

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Aronson JK, Heneghan C, Ferner RE. Br J Clin Pharmacol. Epub 2023 Jul 16.

Addressing drug shortages is a patient safety priority. Part One of this review summarizes existing definitions for drug shortages and the harms that can occur due to drug shortages (e.g., medication errors, treatment delays, undertreatment). Part Two discusses trends in drug shortages, the causes of drug shortages, and potential solutions.

Personal Health Literacy

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Patient Safety Primer August 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.

Nearly all hospital pharmacists say drug shortages are negatively impacting care; a third say impacts are ‘critical.’

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McPhillips D. CNN. August 10, 2023.

Drug shortages present clinicians and patients with numerous challenges. This news story discusses the extensive presence of medication shortages through the experience of health system pharmacists. It quantifies the impacts of drug shortages on effective care as they contribute to the delay, cancelation, or rationing of needed treatments.

The state of health, burnout, healthy behaviors, workplace wellness support, and concerns of medication errors in pharmacists during the COVID-19 pandemic.

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Melnyk BM, Hsieh AP, Tan A, et al. J Occup Environ Med. 2023;65:699-705.

Many healthcare professionals experienced adverse emotional and psychological outcomes during the COVID-19 pandemic. This survey of 665 health system pharmacists found that pharmacists working in settings with higher levels of workplace wellness support were less likely to experience depression, anxiety, or burnout, and report higher levels of professional quality of life during the COVID-19 pandemic.

Incidence and severity of medication reconciliation discrepancies in trauma patients.

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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.

Identification of the barriers and enablers for receiving a speaking up message: a content analysis approach.

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Barlow M, Morse KJ, Watson B, et al. Adv Simul (Lond). 2023;8:17.

Patient safety is improved when all members of the care team feel empowered to speak up about concerns. Equally important is the way the receiver understands and responds to the concern. Through an interprofessional simulation, this study assessed barriers and enablers of receiving a safety concern expressed by a junior nurse, either abruptly or politely and respectfully. Barriers and enablers to receiving the message were about equal no matter the way the concern was expressed, suggesting trainings that focus on speaking up should also focus on receiving those messages.

Risk Evaluation and Mitigation Strategy (REMS) Programs and Medication Safety: Parts I and II.

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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.

Relationship between in-hospital adverse events and hospital performance on 30-day all-cause mortality and readmission for patients with heart failure.

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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.

Hospitalization due to adverse drug events in older adults with cancer: a retrospective analysis.

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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.

A data-driven approach to evaluate barcode-assisted medication preparation alerts at a large academic medical center.

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Joshi RN, Kalaminsky S, Feemster A-A, et al. Jt Comm J Qual Patient Saf. 2023;49:599-603.

Technology, such as barcode scanning, is a recognized method for improving medication safety, but poor design may lead to alert fatigue. This article describes a quality improvement project to reduce barcode-assisted medication preparation alerts in the hospital's pharmacies. More than 40% of alerts were identified as "barcode not recognized," such as packages containing more than one barcode. Problems associated with the highest volume of alerts were resolved with staff education, workflow changes, and changes.

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