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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Curated Libraries

Implementation of Patient Safety Projects Curated Library

May 4, 2023

The implementation of effective patient safety initiatives is challenging due to the complexity of the health care environment. This curated library shares resources summarizing overarching ideas and strategies that can aid in successful program execution, establishment, and sustainability.

Uptake of pharmacist recommendations by patients after discharge: implementation study of a patient-centered medicines review service.

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Basger BJ, Moles RJ, Chen TF. BMC Geriatr. 2023;23:183.

Potentially inappropriate medications (PIM) and polypharmacy, defined as taking 5 or more medications, can increase the risk of hospitalization and other adverse events for older adults. This article describes the implementation and success of a patient-centered medication review conducted at the time of hospital discharge. Nearly all patients followed up with their general practitioner on the pharmacist’s recommendations and approximately three-quarters were implemented. Including the patient and/or caregiver was a key component of the intervention.

Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes.

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WebM&M Case April 26, 2023

This Spotlight Case highlights two cases of falls in older patients in nursing homes. The commentary discusses how risk factors for falls should be considered in care planning and approaches to fall prevention in long-term care settings.

What works in medication reconciliation: an on-treatment and site analysis of the MARQUIS2 study.

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Schnipper JL, Reyes Nieva H, Yoon CS, et al. BMJ Qual Saf. 2023;Epub Mar 22.

Implementing successful interventions to support effective medication reconciliation is an ongoing challenge. The MARQUIS2 study examined whether system- and patient-level interventions plus physician mentors can improve medication reconciliation and reduce medication discrepancies. This analysis based on patient exposure in the MARQUIS2 study found that patient receipt of a best possible medication history (BPMH) in the emergency department and medication reconciliation at admission and discharge were associated with the largest reductions in medication discrepancy rates.

Prevention of perioperative medication errors.

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Nanji K. UpToDate. March 17, 2023.

Perioperative adverse drug events are common and understudied. This review examines factors that contribute to adverse drug events in the surgical setting and discusses prevention strategies that focus on medication reconciliation, technology, standardization, and institutional change.

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.

Impact of pharmacist interventions provided in the emergency department on quality use of medicines: a systematic review and meta-analysis.

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Atey TM, Peterson GM, Salahudeen MS, et al. Emerg Med J. 2023;40:120-127.

Pharmacists are increasingly involved in the emergency department (ED) medication process. This review summarizes the characteristics and impacts of interventions. The most common type of intervention is medication review/reconciliation and/or identification and resolution of medication errors. Interventions including pharmacist co-prescribing or co-charting in the ED resulted in the largest reduction in medication errors.

The impact of medication reconciliation and review in patients using oral chemotherapy.

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Darcis E, Germeys J, Stragier M, et al. J Oncol Pharm Pract. 2023;29:270-275.

Medication errors are common in patients using oral chemotherapy. In this study, a hospital pharmacist identified medication discrepancies in nearly 75% of patients starting oral chemotherapy, with an average of two discrepancies per patient. The pharmacist followed up with the patient’s oncologist via the electronic health record, and the oncologist could accept or reject the pharmacist’s recommendation. Patient outcomes were not evaluated in this study.

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.

Use of complete medication history to identify and correct transitions-of-care medication errors at psychiatric hospital admission.

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Vargas V, Blakeslee WW, Banas CA, et al. PLoS ONE. 2023;18:e0279903.

Medication reconciliation can help identify medication discrepancies during transitions of care. This study examined the impact of a complete medication history database to support pharmacist-led medication reconciliation and identification of medication discrepancies during the admission process for patients at one psychiatric hospital. A retrospective analysis identified 82 medication errors; 90% of these errors – primarily dosage discrepancies and omissions – could have led to patient harm if not corrected through pharmacist intervention.

Hospital-Acquired Diabetic Ketoacidosis.

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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.

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

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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.

Guiding Principles to Achieve Continuity in Medication Management.

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Department of Health and Aged Care. Canberra ACT: Commonwealth of Australia; 2022. ISBN 978-1-76007-471-5.

Originally published in 2005, these Guiding Principles outlines 10 guiding principles to support medication management as patients transfer from one care environment to another, both within one care setting (e.g., hospital) and between care settings (e.g., hospital to long term care). The Guiding Principles are person centered, equity, and coordination and collaboration.

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

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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.

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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.

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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.

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

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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.

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

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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.

Challenges and strategies for patient safety in primary care: a qualitative study.

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Yuan CT, Dy SM, Yuanhong Lai A, et al. Am J Med Qual. 2022;37:379-387.

Patient safety in ambulatory care settings is receiving increased attention. Based on interviews and focus groups with patients, providers, and staff at ten patient-centered medical homes, this qualitative study explored perceived facilitators and barriers to improving safety in ambulatory care. Participants identified several safety issues, including communication failures and challenges with medication reconciliation, and noted the importance of health information systems and dedicated resources to advance patient safety. Patients also emphasized the importance of engagement in developing safety solutions. A recent PSNet perspective discusses patient safety challenges in ambulatory care, particularly during the COVID-19 pandemic.

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

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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.

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