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 242 Results

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.

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.

Pharmacy e-prescription dispensing before and after CancelRx implementation.

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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%.

California pharmacies are making millions of mistakes. They’re fighting to keep that secret.

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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.

Handling injectable medications in anaesthesia: Guidelines from the Association of Anaesthetists.

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Kinsella SM, Boaden B, El‐Ghazali S, et al. Anaesthesia. 2023;78:1285-1294.

Anesthesia provision is a high-risk practice. This guidance provides practical steps to ensure perioperative medication delivery is as safe as possible. This material recommends approaches for both clinicians and organizations to enable collaborative safety efforts in anesthesia, including prefilled syringes, standardization, and adherence to safe labeling practices.

The state of health, burnout, healthy behaviors, workplace wellness support, and concerns of medication errors in pharmacists during the COVID-19 pandemic.

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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.

Status of patient safety culture in community pharmacy settings: a systematic review.

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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.

Risk Evaluation and Mitigation Strategy (REMS) Programs and Medication Safety: Parts I and II.

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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.

A data-driven approach to evaluate barcode-assisted medication preparation alerts at a large academic medical center.

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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.

A hard look at hard stops and workarounds in the acute care setting.

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ISMP Medication Safety Alert! Acute care edition. June 29, 2023;28(13);1-4.

Hard stops in the electronic medical record prevent continuation of ordering, dispensing, or administering an unsafe medication to a patient. This article presents system-level recommendations to effectively introduce hard stops such as including physicians and pharmacists in decision making to reduce risk of workarounds in the future.

ISMP Targeted Medication Safety Best Practices for Community Pharmacy.

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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.

Creating a stronger culture of safety within US community pharmacies.

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Lewis NJW, Marwitz KK, Gaither CA, et al. Jt Comm J Qual Patient Saf. 2023;49:280-284.

Community pharmacies face unique challenges in ensuring patient safety. This commentary summarizes research on prescribing errors in community pharmacies and how a culture of safety in community pharmacies can drive improvements in prescribing safety.

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.

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.

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.

Improving administration and documentation of enteral nutrition support therapy in a Veteran Affairs health care system: use of medication administration record and bar code scanning technology.

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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.

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.

Medication safety incidents associated with the remote delivery of primary care: a rapid review.

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Gleeson LL, Clyne B, Barlow JW, et al. Int J Pharm Pract. 2023;30:495-506.

Remote delivery of care, such as telehealth and e-prescribing, increased sharply at the beginning of the COVID-19 pandemic. This rapid review was conducted to determine the types and frequency of medication safety incidents associated with remote delivery of primary care prior to the pandemic. Fifteen articles were identified covering medication safety and e-prescribing; none of these studies associated medication safety and telehealth.

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