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 1047 Results

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.

Evaluation of policies limiting opioid exposure on opioid prescribing and patient pain in opioid-naive patients undergoing elective surgery in a large American health system.

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Rennert L, Howard KA, Walker KB, et al. J Patient Saf. 2023;19:71-78.

High-risk opioid prescribing can increase the risk of abuse and overdose. This study evaluated the impact of four opioid prescribing policies for opioid-naïve patients – nonopioid medications during surgery, decreased opioid doses in operating rooms, standardized electronic health record alerts, and limits on postoperative opioid supply – implemented by one opioid stewardship program in a large US healthcare system between 2016 and 2018. Post-implementation, researchers observed decreases in postoperative opioid prescription doses, fewer opioid prescription refills, and less patient-reported discharge pain.

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.

Association between opioid tapering and subsequent health care use, medication adherence, and chronic condition control.

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Magnan EM, Tancredi DJ, Xing G, et al. JAMA Netw Open. 2023;6:e2255101.

Rates of prescription opioid misuse and abuse led to recommendations for dose tapering for patients with chronic pain. However, concerns have been raised about the potential harms associated with rapidly decreasing doses or discontinuing opioids. Building on previous research, these researchers used a large claims database to explore the unintended negative consequences of tapering patients on stable, long-term opioid therapy. Findings indicate that opioid tapering was associated with fewer primary care visits, greater numbers of emergency department visits, and reduced adherence to antihypertensive and antidiabetic medications.

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.

Intended and unintended consequences: changes in opioid prescribing practices for postsurgical, acute, and chronic pain indications following two policies in North Carolina, 2012-2018 - controlled and single-series interrupted time series analyses.

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Maierhofer CN, Ranapurwala SI, DiPrete BL, et al. Drug Alcohol Depend. 2023;242:109727.

A national focus on reducing opioid misuse and abuse has resulted in changes to opioid prescribing policies and practice. This retrospective longitudinal study explored changes in prescribing rates, supply and dose of opioid prescriptions after changes in opioid prescribing policies in North Carolina. Researchers found that that prescribing patterns for acute and postsurgical pain patients (but not chronic pain patients) decreased after a state medical board initiative to reduce high-dose and high-volume. Further, new legislation to limit initial opioid prescriptions for acute and postsurgical pain led to a decrease in prescribing for cancer patients with chronic pain, but did not lead to reductions among patients with acute, postsurgical, or non-cancer chronic pain.

Preventable harm because of outpatient medication errors among children with leukemia and lymphoma: a multisite longitudinal assessment.

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Wong CI, Vannatta K, Gilleland Marchak J, et al. Cancer. 2023;Epub Jan 27.

Children with complex home care needs, such as children with cancer, are particularly vulnerable to medication errors. This longitudinal study used in-home observations and chart review to monitor 131 pediatric patients with leukemia or lymphoma for six months and found that 10% experienced adverse drug events due to medication errors in the home and 42% experienced a medication error with the potential for harm. Failures in communication was the most common contributing factor. Findings underscored a critical need for interventions to support safe medication use at home. Researchers concluded that improvements addressing communication with and among caregivers should be co-developed with families and based on human-factors engineering.

The incidence of opioid misuse among the surgical patients with persistent opioid use.

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Namiranian, MD, PhD K. J Opioid Manag. 2023;19:69-76.

Prescription opioids are commonly used to manage surgical and non-surgical pain but misuse of opioids is a serious patient safety concern. In this retrospective cohort study of Veterans Health Administration patients, researchers found that opioid misuse among previously opioid-naïve patients increases significantly after 11 months of chronic use, regardless of whether the opioid was prescribed for surgical or non-surgical pain.

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.

Long-Term Trends of Psychotropic Drug Use in Nursing Homes.

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Grimm CA. Washington DC: Office of the Inspector General; Nov 2022. Report no. OEI-07-20-00500.

Misdiagnosis can result in inappropriate medication use. This report examined the overuse of antipsychotics in nursing homes and resident harms. These recommendations from the U.S. Department of Health and Human Services Office of the Inspector General include heightened evaluation and oversight of medication use and better documentation of diagnosis with medication orders as avenues for improvement.

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.

FDA and ISMP Lists of Look-Alike Drug Names With Recommended Tall Man Letters.

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Food and Drug Administration and Institute for Safe Medication Practices. Plymouth Meeting, PA; Institute for Safe Medication Practices; January 2023.

Mistakes associated with look-alike medication names are a safety concern in health care. Tall man, or mixed case, lettering is one recommended strategy to reduce confusion associated with similarities in drug names. This list includes medications recognized by clinicians and professional organizations as those suited for the application of mixed case lettering to make their use safer.

Medication use evaluation of high-dose long-term opioid de-prescribing in multiple Veterans Affairs medical centers.

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Barrett AK, Sandbrink F, Mardian A, et al. J Gen Intern Med. 2022;37:4037-4046.

Opioid medication use is associated with an increased risk of adverse events; however research has shown sudden discontinuation of opioids is also associated with adverse events such as withdrawal and hospitalization. This before and after study evaluated the impact of the VA’s Opioid Safety Initiative (OSI) on characteristics and prescribing practices. Results indicate that length of tapering period increased, and mortality risk decreased following OSI implementation.

Effect of prescriber notifications of patient’s fatal overdose on opioid prescribing at 4 to 12 months: a randomized clinical trial.

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Doctor JN, Stewart E, Lev R, et al. JAMA Netw Open. 2023;6:e2249877.

Research has shown that prescribers who are notified of a patient’s fatal opioid overdose will decrease milligram morphine equivalents (MME) up to 3 months following notification as compared to prescribers who are not notified. This article reports on the same cohort’s prescribing behavior at 4-12 months. Among prescribers who received notification, total weekly MME continued to decrease more than the control group during the 4-12 month period.

Balancing safety, comfort, and fall risk: an intervention to limit opioid and benzodiazepine prescriptions for geriatric patients.

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Bloomer A, Wally M, Bailey G, et al. Geriatr Orthop Surg Rehabil. 2022;13:215145932211256.

Opioid use by older adults increases the risk of falls. This study examined electronic health record data to determine the proportion of older adults presenting to the emergency room or urgent care due to a fall who receive an opioid prescription, particularly those with at least one risk factor for misuse. Nearly one third of patients received a prescription for an opioid and/or benzodiazepine, and 11% had at least one risk factor for misuse.

Medication errors: the year in review: January through December 2021.

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Pharmacy Practice News Special Edition. December 13, 2022: 43-54.

Medication errors continue to occur despite long-standing efforts to reduce them. This article summarizes types of errors submitted to the Institute for Safe Medication Practices reporting program in 2021. The piece discusses the medications involved, recommendations for improvement, and technologies to be employed to minimize error occurrence.

Lessons learned in implementing a chronic opioid therapy management system.

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Carlile N, Fuller TE, Benneyan JC, et al. J Patient Saf. 2022;18:e1142-e1149.

The opioid epidemic has prompted national and institutional guidelines for safe opioid prescribing. This paper describes the development, implementation, and sustainment of a toolkit for safer opioid prescribing for chronic pain in primary care. The authors describe organizational, technical, and external barriers to implementation along with attempted solutions and their effects. The toolkit is available as supplemental material.

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