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 1633 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.

The complexities of communication at hospital discharge of older patients: a qualitative study of healthcare professionals' views.

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Cam H, Wennlöf B, Gillespie U, et al. BMC Health Serv Res. 2023;23:1211.

When patients are discharged from the hospital, they (and their informal caregivers) are given copious amounts of information that must also be communicated to their primary care provider. This qualitative study of primary care and hospital physicians, nurses, and pharmacists highlights several barriers to complete and effective communication between levels of care, particularly regarding geriatric medication safety. Barriers include the large number of complex patients and incongruent expectations of responsibility of primary and hospital providers. Support systems, such as electronic health records, can both enable and hinder communication.

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.

Informatics tools in deprescribing and medication optimization in older adults: development and dissemination of VIONE methodology in a high reliability organization.

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Winter SG, Sedgwick C, Wallace-Lacey A, et al. Clin Ther. 2023;45:928-934.

The VIONE (Vital, Important, Optional, Not indicated, and Every medication has an indication) tool is used to reduce polypharmacy and potentially inappropriate prescribing. This article provides an overview of VIONE implementation and dashboards used to track VIONE implementation and its impact on prescribing across over 130 Veterans Health Administration medical centers. Since implementation in 2016, VIONE has led to the discontinuation of over 1.6 million medication orders by more than 15,000 providers.

Medication Safety for Look-alike, Sound-alike Medicines.

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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.

Prescription for disaster: America's broken pharmacy system in revolt over burnout and errors.

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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.

Making Healthcare Safer IV: A Continuous Updating of Patient Safety Harms and Practices.

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Rockville, MD: Agency for Healthcare Research and Quality: November 2023.

Patient safety progress is dynamic, consistently producing evidence for application to generate improvements. This report is the fourth in a series funded by the Agency for Healthcare Research and Quality to track a prioritized set of emerging and existing safety approaches to confirm their value and effectiveness. This report will be compiled as new conclusions are formulated. Each review will be posted to the collection as they are completed. The first three Making Healthcare Safer reports, published in 2001, 2013, and 2020, have each served as a consolidated evidence source for clinicians, health system leadership, researchers, and government agencies. Chapter protocols and the results of an examination on patient and family engagement and report cards as a surgical improvement mechanism are now available.

The hospital ran out of her child's cancer drug. Now she's fighting to end shortages.

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Noguchi Y. Health Shots and All Things Considered. National Public Radio. October 23, 2023.

Drug shortages, while often discussed as a system failure, demonstrate harm at an individual level. This story highlights the work of a patient activist who was inspired by the threat to her daughter’s care posed by a lack of chemotherapy availability, to provide needed medications during system disruptions to keep patients safe.

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.

Intervention of pharmacist included in multidisciplinary team to reduce adverse drug event: a qualitative systematic review.

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Zaij S, Pereira Maia K, Leguelinel-Blache G, et al. BMC Health Serv Res. 2023;23:927.

An increasing strategy to reduce adverse drug events (ADE) is pharmacist medication review, typically involving other members of the care team. This qualitative review summarizes randomized studies of interventions with multidisciplinary care teams to reduce ADE. Most interventions were time-intensive (1- to 2-hours), including four steps (data collection, appraisal report, multidisciplinary medication review, follow up). Most teams consisted of a pharmacist, physician, and nurse, although some included other providers such as psychologists or social workers.

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.

Bringing the equity lens to patient safety event reporting.

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Gandhi TK, Schulson LB, Thomas AD. Jt Comm J Qual Patient Saf. 2023;Epub Sept 12.

Safety event reporting from both providers and patients is subject to bias. The authors of this commentary present several ways bias is introduced into reporting and offers strategies to ensure events are reported and analyzed in an equitable manner.

Flow of information contributing to medication incidents in home care- an analysis considering incident reporters' perspectives.

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Vellonen M, Härkänen M, Välimäki T. J Clin Nurs. 2023;Epub Oct 6.

Ensuring medication safety in home care settings has unique challenges. In this study, researchers analyzed 1,027 incident reports involving medication errors and communication between home care and inpatient care settings. Four types of issues were identified – (1) information management such as incomplete medication lists or fragmentation of patient data, (2) cooperation between care team members, (3) work environment and lack of resources, and (4) individual-level factors, such as inadequate skills or human error.

A multi-method exploratory evaluation of a service designed to improve medication safety for patients with monitored dosage systems following hospital discharge.

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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.

Right Kind of Wrong: Why Learning to Fail can Teach us to Thrive.

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Edmondson A. Atria Books, New York, 2023. ISBN: 9781982195069.

Despite the harm that failure can cause, its value as a learning opportunity, if examined through the lens of human error rather than blame, cannot be understated. This book explores how failure that happens in new situations provides new insights toward goal achievement, utilizes knowledge and capitalizes on even small missteps, and can enhance and inform improvement.

A survey of pharmacists' perception of the work environment and patient safety in community pharmacies during the COVID-19 pandemic.

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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.

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.

Look-alike medications in the perioperative setting: scoping review of medication incidents and risk reduction interventions.

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Ryan AN, Robertson KL, Glass BD. Int J Clin Pharm. 2023;Epub Sep 9.

Look-alike medications can cause confusion and contribute to medication administration errors. This scoping review including 18 articles identified several risk reduction strategies to mitigate look-alike medication errors in perioperative settings, such as improved labelling and standardization of storage. The authors note that further research is needed to assess the effectiveness of technology-based solutions, such as automated dispensing cabinets.

Reduced postdischarge incidents after implementation of a hospital-to-home transition intervention for children with medical complexity.

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Huth K, Hotz A, Emara N, et al. J Patient Saf. 2023;19:493-500.

The transition from hospital to home is a vulnerable time as patients may have changes in medications or care needs, or difficulties accessing follow up with an outpatient provider. To reduce adverse events (AE), rehospitalizations, and emergency department visits, this hospital developed a structured discharge bundle based on the I-PASS tool used for inpatient handoffs. AE, rehospitalizations, and emergency department visits were all reduced following implementation of the I-PASS bundle.

Why admitting to mistakes can help doctors (and patients).

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McDonald T. TEDxSanDiego. September 23, 2023.

The lack of a safety culture fundamentally restricts the ability of clinicians to address mistakes, psychologically deal with them and learn. The CANDOR system is highlighted in this presentation by one of the originators of the concept as a strategy for successful resolution, learning and support for those involved in medical error.

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