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 1543 Results

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.

Minimize medication errors in urgent care clinics.

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Coffey SB. American Nurse Journal. Epub March 2, 2023.

Urgent care clinics offer services to a wide patient base that increase the complexities of medication prescribing and administration. Safety culture, process, and structural factors are discussed as avenues to increase safety in this unique ambulatory setting. The piece highlights the importance of education, rules, and storage procedures to ensure safe medication administration.

Controlled substance drug diversion by healthcare workers as a threat to patient safety.

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ISMP Medication Safety Alert! Acute care edition. February 23, 2023;28(4):1-4; March 9, 2023:28(5):1-4.

Drug diversion can reduce patient safety and should be addressed at a system level to reduce its occurrence and impact. Part I of this two-part series examines ways in which drug diversion can affect care teams, and outlines what to watch for to flag its occurrence at the clinician, record keeping, and medication inventory levels. Part II shares tactics to minimize controlled substance diversion, and track, document and take action when it does occur.

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Value and Patient Safety

March 8, 2023

Value as an element of patient safety is emerging as an approach to prioritize and evaluate improvement actions. This library highlights resources that explore the business case for cost effective, efficient and impactful efforts to reduce medical errors.

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.

Using Failure Mode, Effect and Criticality Analysis to improve safety in the cancer treatment prescription and administration process.

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Buja A, De Luca G, Ottolitri K, et al. J Pharm Policy Pract. 2023;16:9.

Failure Mode, Effect and Criticality Analysis (FMECA) is a prospective method for identifying and preventing potential error risks. Using FMECA, public health medical residents calculated a Risk Priority Number (RPN), or criticality, for each possible failure mode in cancer treatment prescription and administration. Each phase of the cancer treatment process had at least one critical step identified, and actions were developed to reduce the likelihood of the error occurring and/or to increase the likelihood of the error being detected.

Medication rounds: a tool to promote medication safety for children with medical complexity.

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Rojas CR, Moore A, Coffin A, et al. Jt Comm J Qual Patient Saf. 2023;49:226-234.

Children with complex medical conditions are particularly vulnerable to medication errors. This article describes the development and implementation of a pharmacy-led medication rounding care model for children with medical complexity wherein clinicians and pharmacists conduct weekly reviews of all patient medications using a standardized checklist.

Evaluation of effectiveness and safety of pharmacist independent prescribers in care homes: cluster randomised controlled trial.

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Holland R, Bond CM, Alldred DP, et al. BMJ. 2023;380:e071883.

Careful medication management in long-term care residents is associated with improved hospital readmission rates and reduced fall rates. In the UK, pharmacist independent prescribers (PIP) can initiate, change, or monitor medications, and this cluster randomized controlled trial evaluated the effect of PIPs on fall rates. After six months of PIP involvement, fall rates (the primary outcome) were not statistically different than the usual care group, although drug burden was reduced.

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.

Examining medication ordering errors using AHRQ Network of Patient Safety Databases.

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Grauer A, Rosen A, Applebaum JR, et al. J Am Med Inform Assoc. 2023;Epub Jan 30.

Medication errors can happen at any step along the medication pathway, from ordering to administration. This study focuses on ordering errors reported to the AHRQ Network of Patient Safety Databases (NPSD) from 2010 to 2020. The most common categories of ordering errors were incorrect dose, incorrect medication, and incorrect duration; nearly 80% of errors were definitely or likely preventable.

Shape matters: a neglected feature of medication safety: why regulating the shape of medication containers can improve medication safety.

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Bitan Y, Nunnally ME. J Med Syst. 2022;47:6.

Hospitals, pharmacies, and organizations have developed numerous strategies to prevent look-alike/sound-alike medication mix-ups, but these errors continue to occur. This article suggests a human factors approach by changing the shape of the container for each medication class-type, thus reducing clinicians’ cognitive load. Importantly, drug manufacturers would need to agree on container shapes to prevent confusion when drugs are ordered from different suppliers.

Pump up the volume: how to prioritize events and analyze error data.

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ISMP Medication Safety Alert! Acute care edition. February 9, 2023;28(3):1-4.

Patient safety event reporting is an established component of a learning strategy. This article explores weaknesses in siloed error reporting mechanisms and recommends analysis efforts as key to design and prioritize actions to use in tandem with reporting to result in lasting system changes and enhanced patient safety.

Is anybody 'Learning' from deaths? Sequential content and reflexive thematic analysis of national statutory reporting within the NHS in England 2017-2020.

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Brummell Z, Braun D, Hussein Z, et al. BMJ Open Qual. 2023;12:e002093.

In 2017, England’s National Health Service (NHS) implemented the Learning from Deaths program which requires NHS Secondary Care Trusts (NSCT) to report, investigate, and learn from potentially preventable deaths. This study focuses on what NCSTs learned during the first three years of the program, the actions taken in response and their impact, and engagement with Learning from Deaths. Trusts appear to have varied understanding and use of the term ‘learning’ and not all specified the impact their actions had on patient safety.

How would final-year medical students perform if their skill-based prescription assessment was real life?

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Kalfsvel L, Hoek K, Bethlehem C, et al. Br J Clin Pharmacol. 2022;88:5202-5217.

Medication errors are common, especially among medical trainees. This retrospective cohort study conducted at one medical center in the Netherlands identified a high rate of errors in prescriptions written by medical students (40% of all prescriptions). The most common type of error was inadequate information in the prescription – such as not indicating the dosage form or concentration, or missing usage instructions, or omitting the weight for a pediatric patient. Findings indicate that 29% of errors would not have been intercepted and resolved by an electronic prescribing system or pharmacist.

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.

ISMP updates its list of drug names with tall man (mixed case) letters based on survey results.

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ISMP Medication Safety Alert! Acute care edition. January 26, 2023:28(2):1-4.

Look-alike and sound-alike drug names are a perpetual cause for confusion that decreases medication safety. This article discusses the results of a national survey on the importance of mixed case drug names, which found that 94% of the 298 respondents reported using mixed case drug names in their organization and that the majority of participants felt that mixed case lettering prevents drug selection events. The survey also identified new drug names for inclusion on the 2023 list revision.

Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts.

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WebM&M Case February 1, 2023

A 38-year-old man with end-stage renal disease (ESRD) on chronic hemodialysis was admitted for nonhealing, infected lower leg wounds and underwent a below-knee amputation. He suffered from postoperative pain at the operative stump and was treated for four days with regional nerve blocks, as well as gabapentin, intermittent intravenous hydromorphone (which was transitioned to oral oxycodone) and oral hydromorphone.

Latent and active failures perfectly align to allow a preventable adverse event to reach a patient.

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ISMP Medication Safety Alert! Acute care edition. January 12, 2023;28(1):1-4.

The patient safety movement has raised awareness of the presence of multiple factors that align to result in patient harm, yet implementing processes to fully examine and change practice from that perspective is challenged. This article discusses this situation and provides recommendations to orient improvement efforts toward deeper investigation methods to identify latent contributors to care failure.

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