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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 280 Results

Galappatthy P, Mair A, Dhingra-Kumar N et al. Geneva, Switzerland: World Health Organization; 2023. ISBN 9789240058897.

Look-alike, sound-alike (LASA) medicines are known contributors to drug errors. This report discusses how name and label similarities degrade care, and the actions organizations and individual practitioners can take to mitigate the potential of LASA medication errors that cause harm. The authors discuss obstacles and enablers to implementing prevention strategies.

Le Coz E. USA Today. October 26, 2023.

Chain pharmacies provide prescriptions in an environment that facilitates error due to production pressures, poor error reporting, and a lack of safety culture. This feature story examines working conditions at primary retail pharmacies in the United States and draws from staff experiences, industry data and frontline evidence to illustrate the problem as a threat to patient safety.
Alqenae FA, Steinke DT, Belither H, et al. Drug Saf. 2023;46:1021-1037.
Miscommunication between hospitals and community pharmacists at patient discharge can result in incorrect or incomplete medication distribution to patients. This study describes utilization and impact of the Transfers of Care Around Medicines (TCAM) service post-hospital discharge at community pharmacies. An increasing percentage of TCAM referrals were completed post-intervention, but 45% were not completed at all or took longer than one month. The impact of the TCAM service on adverse drug events (ADE) and unintentional medication discrepancies (UMD) was uncertain. Future research may explore reasons for low/late completions or focus on high-risk medications, as those were associated with the most ADE and UMD.
Ljungberg Persson C, Nordén Hägg A, Södergård B. Explor Res Clin Soc Pharm. 2023;12:100327.
Increases in clinician workload can increase the risk of medical errors. This survey of Swedish community pharmacists found that while perceived workload increased and work environment decreased during the COVID-19 pandemic, there was no perceived impact on patient safety. Findings underscore the importance of effective communication between management and frontline healthcare workers during crises.
Parry D, Odedra A, Fagbohun M, et al. Br J Oral Maxillofac Surg. 2023;61:509-513.
Misleading or unclear abbreviations can cause communication errors and threaten patient safety. This article highlights how lessons learned regarding abbreviations in aviation can apply to healthcare to avoid abbreviation-related medical errors, such as prescribing errors.
O’Mahony D, Cherubini A, Guiteras AR, et al. Eur Geriatr Med. 2023;14:625-632.
STOPP (Screening Tool of Older Persons’ Prescriptions) and START (Screening Tool to Alert to Right Treatment) criteria are used to identify potentially inappropriate prescribing in older adults. This article describes the consensus process to update and validate the third version of the STOPP/START criteria using evidence from a systematic review and input from a panel with expertise in geriatric pharmacology. The consensus process resulted in additional STOPP criteria (133 versus 80 in version 2) and START criteria (57 versus 34 in version 2). The additional criteria in version 3 can help clinicians detect and prevent adverse drug-drug and drug-disease interactions.
Pitts SI, Olson S, Yanek LR, et al. JAMA Intern Med. 2023;183:1120-1126.
Previous research has found that CancelRx can improve communication between electronic health record (EHR) systems and pharmacy dispensing systems and increase successful medication discontinuation. This interrupted time series analysis assessed the impact of CancelRx implementation on successful discontinuation of medications e-prescribed in ambulatory healthcare settings. After CancelRx implementation, the proportion of e-prescriptions sold after discontinuation in the EHR decreased from 8.0% to 1.4%.

Peterson M. Los Angeles Times. September 5, 2023.

Safe practice in community pharmacy is challenged by production pressure, workforce shortages, and multitasking. This story examined the mistakes made at major retail pharmacy chains in California. It provides examples perpetrated across the industry to target universal areas of needed improvement and potential strategies to address them.

Stratford, London; The National Guardian.

Organizational efforts to collect and respond to the concerns of staff and patients are a cornerstone to patient safety improvement despite challenges to implement them. This annual report presents insights drawn from problems staff share with Freedom to Speak Up Guardians in the United Kingdom to capitalize on problems to drive improvement. The 2023 report summarized data collected from over 25,000 cases recorded.

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.
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.
Kwon K-E, Nam DR, Lee M-S, et al. J Patient Saf. 2023;19:353-361.
Community pharmacists are perhaps the last line of defense in preventing medication errors in the outpatient setting; therefore, ensuring a strong safety culture is critical. This review identified 11 studies reporting on safety culture using the AHRQ Community Pharmacy Survey on Patient Safety Culture. Pharmacists and pharmacy staff rated overall patient safety highly, but more than half identified workload as a concern.

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.

May 31, 2023; Fed Register;88:35694-35728.

Standardized medication labels have been shown to increase patient comprehension and adherence. The Food and Drug Administration (FDA) is proposing a rule which, if approved, would require an easily understandable, one-page medication guide be given to patients when receiving medication in the outpatient setting. Written comments may be submitted through November 27, 2023.
Conn R, Fox A, Carrington A, et al. Pharmaceutical Journal. 2023;310:7973.
Children are particularly vulnerable to medication errors. Weight- and age-based dosing, different medication formulations, and miscommunication with parents and caregivers contribute to errors. Data-driven education and peer feedback have been noted as effective strategies to reduce prescribing errors.
Poiraud C, Réthoré L, Bourdon O, et al. Infect Dis Now. 2023;53:104641.
Vaccine errors can limit the effectiveness of immunization efforts. Based on survey data from 227 health professionals in France, this study identified several areas for improvement related to knowledge of vaccine-related errors, such as contraindications during pregnancy, vaccine storage, age-related vaccine schedules, and vaccine administration.

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.
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.
Abebe E, Bao A, Kokkinias P, et al. Explor Res Clin Soc Pharm. 2023;9:100216.
The patient safety movement recognizes that most errors occur at the system level, not the individual level, and therefore uses a systems approach toward improving patient safety. A similar systems approach can be used by pharmacy programs to enhance the education of pharmacy students. This article describes the sociotechnical framework of healthcare (structures, processes, outcomes) and parallels with pharmacy programs.
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.