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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 257 Results
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.

Grailey K, Hussain R, Wylleman E, et al. BMC Nurs. 2023;22:378.
Barcode medication administration (BCMA) technology reduces risk of many types of medication errors (e.g., wrong drug, wrong patient, omission). This qualitative study of nurses in low- and high-BCMA-use hospital wards describes barriers and facilitators to use. Barriers were consistent across use levels, suggesting that team culture and accountability play a crucial role in increasing BCMA use.
Reale C, Ariosto DA, Weinger MB, et al. J Gen Intern Med. 2023;38:982-990.
Barcode mediation administration (BCMA) can reduce medication errors, but workarounds can hinder its effectiveness. Using simulations, this study explored potential medication-related errors associated with BCMA during an electronic health record (EHR) transition. The study was able to identify potential problems with both the old and new systems and provide performance data against which to benchmark future system and/or workflow changes.
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.

ISMP Medication Safety Alert! Acute Care edition. 2023;28(19):1-3.

Lack of experience with distinct processes and products can lay the foundation for mistakes. This article examines an instance when a colonoscopy preparation product was switched with a dialysis fluid, a barcoding system didn’t recognize the substitution, and a patient died. Barcode identification, solution availability and staffing improvements are discussed to minimize opportunities for the systemic failures contributing to harm.

Banks MA. Specialty Pharmacy Continuum. September 15, 2023.

Radiofrequency identification (RFID) devices are being used to improve processes in the operating room and prevent errors. This article examines the use of RFID tracking to build reliability into operating room anesthesia medication refiling process. The experience at one hospital found that the RFID process reduced errors, while increasing the task completion time.
Hogerwaard M, Stolk M, Dijk L van, et al. BMJ Open Qual. 2023;12:e002023.
Barcode medication administration (BCMA) technology is a useful tool to reduce medication administration errors (MAE) in the operating room. This study used a pre-post design to estimate the rate of MAE before and after BCMA implementation on infusion pumps. MAE were significantly reduced and up to 90% of errors were considered preventable, if the staff had utilized BCMA. Reasons for not using BCMA included unreadable barcodes, lack of time, and resistance to new processes.
Joshi RN, Kalaminsky S, Feemster A-A, et al. Jt Comm J Qual Patient Saf. 2023;49:599-603.
Technology, such as barcode scanning, is a recognized method for improving medication safety, but poor design may lead to alert fatigue. This article describes a quality improvement project to reduce barcode-assisted medication preparation alerts in the hospital's pharmacies. More than 40% of alerts were identified as "barcode not recognized," such as packages containing more than one barcode. Problems associated with the highest volume of alerts were resolved with staff education, workflow changes, and changes.
Ye J. JMIR Periop Med. 2023;6:e34453.
Perioperative medication errors are common. This article highlights several interventions to reduce the risk of perioperative medication errors, including improved medication labeling, adoption of artificial intelligence for decision support and risk prediction, and the use of health information technology (IT), such as computerized physician order entry (CPOE), electronic medication administration records (eMAR), and barcode medication administration (BCMA).

ISMP Medication Safety Alert! Acute care edition. June 1, 2023; 28(11):1-6.

Oxytocin, which is commonly used to induce labor, has been associated with adverse events. Based on 2,073 oxytocin-related medication errors reported to one patient safety organization, the authors of this article summarize the common event types (e.g., pump misprogramming, incorrect infusion set-up, or use of incorrect drug or concentration) and highlight several recommendations to increase safe oxytocin administration.

Horsham, PA; Institute for Safe Medication Practices: April 2023.

Community pharmacies are common providers of medication delivery that harbor process weaknesses affecting safety. This guidance shares evidence-based steps to address problems such as wrong patient errors and lack of consistent barcode system use in the community setting.
Taft T, Rudd EA, Thraen I, et al. J Am Med Inform Assoc. 2023;30:809-818.
Medication administration errors are major threats to patient safety. This qualitative study with 32 nurses from two US health system explored medication administration hazards and inefficiencies. Participants identified ten persistent safety hazards and inefficiencies, including issues with communication between safety monitoring systems and nurses, alert fatigue, and an overreliance on medication administration technology. These findings highlight the importance of developing medication administration technology in collaboration with frontline nurses who are tasked with medication administration.
Curated Libraries
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.
Chew MM, Rivas S, Chesser M, et al. J Patient Saf. 2023;19:23-28.
Provision of enteral nutrition (EN) is a specialized process requiring careful interdisciplinary teamwork. After discovering significant issues with ordering, administration, and documentation of EN, this health system updated its workflows to improve safety. EN therapies were added to the electronic medication administration record (MAR) and the barcoding system was updated. After one year, all EN orders were barcode scanned and nearly all were documented as given or included a reason why they were not given.

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.
Mohanna Z, Kusljic S, Jarden R. Aust Crit Care. 2022;35:466-479.
Many types of interventions, such as education, technology, and simulations, have been used to reduce medication errors in the intensive care setting. This review identified 11 studies representing six intervention types; three of the six types showed improvement (prefilled syringe, nurses’ education program, and the protocolized program logic form) while the other three demonstrated mixed results.
Fuller AEC, Guirguis LM, Sadowski CA, et al. Sr Care Pharm. 2022;37:421-447.
While barcode-assisted medication administration (BCMA) and electronic medication administration records (eMAR) technologies have reduced adverse drug events, workarounds that may contribute to medication errors have been identified for both. This study of medication administration errors was conducted in a Canadian long-term care facility following implementation of eMAR-BCMA software. During the twenty-nine-month study period, 190 medication administration errors were reported.
Passwater M, Huggins YM, Delvo Favre ED, et al. Am J Clin Pathol. 2022;158:212-215.
Wrong blood in tube (WBIT) errors are rare but can lead to complications. One hospital implemented a quality improvement project to reduce WBIT errors with electronic patient identification, manual independent dual verification, and staff education. WBIT errors were significantly reduced and sustained over six years.
Austin JM, Bane A, Gooder V, et al. J Patient Saf. 2022;18:526-530.
Use of bar code medication administration (BCMA) technology in hospitals has been shown to decrease medication errors at the time of administration. In 2016, the Leapfrog Group implemented a standard for BCMA use as part of its hospital survey. This article describes the development, testing, and subsequent refinement of the BCMA standard.
Gauthier-Wetzel HE. Comput Inform Nurs. 2022;40:382-388.
Barcode medication administration (BCMA) has been promoted as an effective method for reducing medication administration errors. In the emergency department of one Veterans Affairs Medical Center, medication error rates decreased by nearly 11% following introduction of BCMA technology. However, unsafe workarounds were also identified, which may limit the overall safety of BCMA.