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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 - 8 of 8 Results

Phipps D, Ashour A, Riste L, et al. The Pharmaceutical Journal. 2020;305(7943, 7944). November 10, December 1, 2020.

Dispensing mistakes are a common contributor to preventable adverse events in community pharmacies. Part 1 of this two-part series discusses factors that contribute to dispensing errors and summarizes methods for managing risks stemming from missteps. Part 2 focuses on preventing situations that enable errors and the role pharmacists have in minimizing dispensing errors in daily practice.

Farnborough, UK: Healthcare Safety Investigation Branch; September 24, 2020. 

Unit-based pharmacy services help to mitigate and catch medication errors. This report highlights a case of a medication error death and describes how embedding clinical pharmacy services could have prevented this incident. The report provides system level recommendations to enhance this service including defining the role of clinical pharmacy teams and prioritizing the tactic as an important improvement strategy.   
Härkänen M, Turunen H, Vehviläinen-Julkunen K. J Patient Saf. 2020;16.
This study compared medication errors detected using incident reports, the Global Trigger Tool method, and direct observations of patient records. Incident reports and the Global Trigger Tool more commonly identified medication errors likely to cause harm. Omission errors were commonly identified by all three methods, but identification of other errors varied. For example, incident reports most commonly identified wrong dose and wrong time errors. The contributing factors also varied by method, but in general, communication issues and human factors were the most common contributors.
Harvey J, Avery AJ, Ashcroft D, et al. Res Social Adm Pharm. 2015;11:216-27.
This qualitative study characterized safety hazards in medication dispensing in community pharmacies. The authors conclude that the major sources of risk pertained to interruptions and distractions, which were often exacerbated by production pressures.
Johnson SJ, O'Connor EM, Jacobs S, et al. Res Social Adm Pharm. 2014;10:885-895.
This internet-based survey of pharmacists in the United Kingdom revealed an association between self-reported medication dispensing errors and higher perceived workload, similar to prior nursing studies. These findings contrast with earlier research that showed no relationship between physician working conditions and errors.
Sujan M-A, Ingram C, McConkey T, et al. BMJ Qual Saf. 2011;20:549-56.
In this study, qualitative interviews with frontline staff were used to identify sources of latent error within an inpatient pharmacy. The potential problems identified, which included issues with the work environment and information technology, were then prospectively monitored over a 6-month period. This process was used to design system improvements.
Cresswell KM, Fernando B, McKinstry B, et al. Br Med Bull. 2007;83.
The authors discuss drug-related adverse events in the elderly and provide practical suggestions for clinicians to improve prescription safety in this patient population.