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.
Rockville, MD: Agency for Healthcare Research and Quality; October 2008.
This AHRQ grantee announcement lists 13 projects funded to demonstrate effective strategies in identifying and addressing risks and in improving processes in ambulatory care.
Murdaugh L, Jordin R. Hosp Pharm. 2010;43:728-733.
This article discusses hospital compliance with National Patient Safety Goals regarding medication safety and describes strategies to improve anticoagulant administration safety.
Nichols P, Copeland T-S, Craib IA, et al. Med J Aust. 2008;188:276-9.
Interviews with clinicians who committed medication errors helped to identify contributing factors, which included understaffing and lack of access to prescribing information at the point of care.
This monthly commentary examines risks associated with mismanagement of IV tubing and ports, discusses a recent article regarding unintended consequences of computerized provider order entry (CPOE), and details recent changes to similarly named medications.
Fanikos J, Cina JL, Baroletti S, et al. Am J Cardiol. 2007;100:1465-9.
This study noted two adverse drug events (ADEs) per 100 patient admissions in hospitalized cardiac patients. Preventable ADEs most frequently occurred during medication administration, and cardiovascular agents and anticoagulants were the most common drug classes involved. Interestingly, the most preventable ADEs occurred between 7:00 AM and 9:00 AM, during handoffs between nurses at shift change. The authors advocate for prevention strategies around medication administration and nursing shift changes to reduce the potential for errors.
This monthly selection of medication error reports provides examples of problems related to abbreviations, electronic prescribing, and communication of critical lab values.
Skibinski KA, White BA, Lin LI-K, et al. Am J Health Syst Pharm. 2007;64:90-6.
The authors implemented technologies supporting safe medication use and observed improved patient identification, decreased turnaround time for orders, and increased accuracy of medication administration.
A nurse notices that an IV medication she is about to administer is possibly mislabeled, as it looks like a different drug. However, she is interrupted before she can call the pharmacy and winds up hanging the bag anyway.