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 1089 Results

Prescription opioid dose reductions and potential adverse events: a multi-site observational cohort study in diverse US health systems.

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Metz VE, Ray GT, Palzes V, et al. J Gen Intern Med. 2023;Epub Nov 6.

In response to the increasing opioid crisis, many medical associations, policy makers, and insurers have argued for dose reductions. However, when doses are reduced too quickly, patients may experience short- and long-term adverse events. Consistent with other studies, dose reductions higher than 30% were associated with higher odds of emergency department visits, opioid overdose, and all-cause mortality in the month following dose reduction.

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.

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.

Anesthesia workspaces for safe medication practices: design guidelines.

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MohammadiGorji S, Joseph A, Mihandoust S, et al. HERD. 2023;Epub Aug 8.

Well-designed workspaces minimize disruptions and distractions. This review and study describes several important ways to improve the anesthesia workspace in the operating room. Recommendations include demarcating an anesthesia zone with adequate space for equipment and storage and that restricts unnecessary staff travel into and through the zone. Each recommendation includes an illustrative diagram, explains its importance, and offers methods to achieve it.

Intravenous (IV) push medications – bridging the gap between education and clinical practice.

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ISMP Medication Safety Alert! Acute Care. November 2, 2023;28(22):1-4.

Intravenous (IV) push medication administration is a primary therapeutic approach where process gaps can result in harm. This article examines existent presence of recognized safe practice education in close to 200 surveyed nursing programs to assess the teaching of standardized practice behaviors at the student level and recommend strategies to embed IV safety into instruction efforts.

Medication safety events after acute myocardial infarction among veterans treated at VA versus non-VA hospitals.

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Weeda ER, Ward R, Gebregziabher M, et al. Med Care. 2023;Epub Oct 4.

Fragmentation of care between inpatient and outpatient settings can lead to poor patient outcomes. Based on a cohort of veterans ages 65 years or older who had a myocardial infarction, this study examined the use of outpatient medications for secondary prevention (e.g., beta blockers, statins) in the preceding 30 days among patients treated at Veterans Health Administration (VA) versus non-VA hospitals. The researchers found that medication omissions, duplications and delays in prescribing of secondary prevention medications were more common among patients treated at non-VA hospitals.

National Patient Safety Goals.

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The Joint Commission.

The National Patient Safety Goals (NPSGs) are one of the major methods by which The Joint Commission establishes standards for ensuring patient safety in all health care settings. In order to ensure health care facilities focus on preventing major sources of patient harm, The Joint Commission regularly revises the NPSGs based on their impact, cost, and effectiveness. Major focus areas include promoting surgical safety, achieving health equity, and preventing hospital-acquired infections, medication errors, inpatient suicide, and specific clinical harms such as falls and pressure ulcers. The 2024 goals are now available.

Adverse drug events caused by three high-risk drug-drug interactions in patients admitted to intensive care units: a multicentre retrospective observational study.

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Klopotowska JE, Leopold J‐H, Bakker T, et al. Br J Clin Pharmacol. 2023;Epub Aug 11.

Identifying and preventing drug-drug interactions (DDI) is critical to patient safety, but the usual method of detecting DDI and other errors - manual chart review - is resource intensive. This study describes the use of an e-trigger to pre-select charts for review that are more likely to include one of three DDIs, thus reducing the overall number of charts needing review. Two of the DDI e-triggers had high positive predictive values (0.76 and 0.57), demonstrating that e-triggers can be a useful method to pre-selecting charts for manual review.

Multicomponent pharmacist intervention did not reduce clinically important medication errors for ambulatory patients initiating direct oral anticoagulants.

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Kapoor A, Patel P, Mbusa D, et al. J Gen Intern Med. 2023;Epub Sep 27.

Pharmacists are frequently involved in medication reviews for hospitalized patients prescribed direct oral anti-coagulants (DOAC). This randomized controlled study explored pharmacist involvement with patients prescribed DOAC in ambulatory care. The intervention included up to three phone calls, electronic health record communication with the prescriber, and recommendations for lab work. After 90 days, there were no differences in clinically important medication errors between groups.

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.

Addressing bias in acute postoperative pain management.

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Harbell MW, Maloney J, Anderson MA, et al. Curr Pain Headache Rep. 2023;27:407-415.

Provider bias may impact the pain management patients receive post-operatively. This review presents recent findings on the types and amounts of pain management patients receive. Results suggest women and people of color receive less pain medication despite reporting higher pain scores. Results regarding socio-economic status and English language proficiency bias are mixed. Implicit bias training, prescribing guidelines for all patients, and culturally competent pain management scales have all been suggested as ways to reduce provider bias and improve pain management.

Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable

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WebM&M Case September 27, 2023

A 14-year-old girl was admitted to the hospital with a new diagnosis of type 1 diabetes mellitus without ketoacidosis. Before discharge, medications intended for home use were delivered to the patient’s bedside, but the resident physician noticed a discrepancy. An insulin pen and pen needles had been ordered, but an insulin vial and extra insulin syringes were delivered. Neither the patient nor the parents had received education on how to draw up and administer insulin using a vial and syringe.

Preventing potential patient harm through clinical content interventions during oncology clinical trial implementation.

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Loo VC, Kim S, Johnson LM, et al. J Patient Saf. 2023;19:460-464.

Ensuring the safety of clinical trial participants is paramount to successful, meaningful clinical research. In this study, researchers examined 585 clinical trial documents and found that 17% included potential patient safety interventions (e.g., resolving medication dosing discrepancies). The authors suggest that clinical specialists’ review of study protocol documents could enhance patient safety during clinical trial conduct.

ISMP Survey on High-Alert Medications in Acute Care Settings.

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Plymouth Meeting, PA: Institute for Safe Medication Practices; 2023.

Experience from the sharp end helps to inform safety improvement initiatives. The results from this field survey will inform the revision of a high-alert medication list used to raise awareness about certain drugs that have heightened potential to cause patient harm if used incorrectly. The deadline for submitting comments is October 20, 2023.

Protocolization of analgesia and sedation through smart technology in intensive care: improving patient safety.

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Ojeda IM, Sánchez-Cuervo M, Candela-Toha Á, et al. Crit Care Nurs. 2023;43:30-38.

High-alert medications can cause serious patient harm if administered incorrectly. This article describes a quality improvement project to reduce medication errors involving high-alert sedative and analgesic medications in the intensive care unit (ICU) through use of protocolized and centralized smart intravenous infusion pump technology. Use of the protocolized software led to the interception of nearly 400 infusion-related programming errors.

Potentially inappropriate medication use is associated with increased risk of incident disability in healthy older adults.

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Lockery JE, Collyer TA, Woods RL, et al. J Am Geriatr Soc. 2023;71:2495-2505.

Potentially inappropriate medications (PIM) are a known contributor to patient harm in older adults. In contrast to most studies of PIM in patients with comorbid conditions or residing in hospitals or nursing homes, this study evaluated the impact of PIM use in community-dwelling older adults without significant disability. Participants with at least one PIM were at increased risk of physical disability and hospitalization over the study period (8 years) than those not taking any PIM. However, both groups had similar rates of death.

Just what the doctor ordered: missed ordering of venous thromboembolism chemoprophylaxis is associated with increased VTE events in high-risk general surgery patients.

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Baimas-George MR, Ross SW, Yang H, et al. Ann Surg. 2023;278:e614-e619.

Hospital-acquired venous thromboembolism (VTE) remains a significant source of preventable patient harm. This study of 4,252 high-risk general surgery patients found that only one-third received care in compliance with VTE prophylaxis guidelines. Patients receiving guideline-compliant care experienced shorter lengths of stay (LOS), fewer blood transfusions, and decreased odds of having a VTE, emphasizing the importance of initiating VTE chemoprophylaxis in high-risk general surgery patients.

Prolonged DKA in Pregnancy: A Case of Communication Breakdown.

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WebM&M Case August 30, 2023

A 31-year-old pregnant patient with type 1 diabetes on an insulin pump was hospitalized for euglycemic diabetic ketoacidosis (DKA). She was treated for dehydration and vomiting, but not aggressively enough, and her metabolic acidosis worsened over several days. The primary team hesitated to prescribe medications safe in pregnancy and delayed reaching out to the Maternal Fetal Medicine (MFM) consultant, who made recommendations but did not ensure that the primary team received and understood the information.

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.

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