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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Curated Libraries

Value and Patient Safety

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.

Curated Libraries

Medication/Drug Errors

January 14, 2022

The medication-use process is highly complex with many steps and risk points for error, and those errors are a key target for improving safety. This Library reflects a curated selection of PSNet content focused on medication and drug errors. Included resources explore understanding harms from preventable medication use, medication safety...

Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions.

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WebM&M Case July 28, 2021

This commentary presents two cases highlighting common medication errors in retail pharmacy settings and discusses the importance of mandatory counseling for new medications, use of standardized error reporting processes, and the role of clinical decision support systems (CDSS) in medical decision-making and ensuring medication safety.

Hyponatremia Secondary to Home Parenteral Nutrition Error

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WebM&M Case May 26, 2021

A 4-year-old (former 33-week premature) boy with a complex medical history including gastroschisis and subsequent volvulus in infancy resulting in short bowel syndrome, central venous catheter placement, and home parenteral nutrition (PN) dependence was admitted with hyponatremia. A pharmacist from the home infusion pharmacy notified the physician that an error in home PN mixing had been identified; a new file had been created for this chronic PN patient by the home infusion pharmacy and the PN formula in this file was transcribed erroneously without sodium acetate.

Learning from errors with the new COVID-19 vaccines.

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ISMP Medication Safety Alert! Acute Care Edition. January 14, 2021;26(1);1-5.

Learning from error rests on transparency efforts buttressed by frontline reports. This article examined reports of COVID-19 vaccine errors to highlight common risks that are likely to be present in a variety of settings and share recommendations to minimize their negative impact, including storage methods and vaccination staff education.

Reducing inappropriate outpatient medication prescribing in older adults across electronic health record systems.

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Friebe MP, LeGrand JR, Shepherd BE, et al. Appl Clin Inform. 2020;11:865-872.

The prescribing of potentially inappropriate medications, particularly among older adults, is an ongoing quality and safety concern. Among adults 65 years and older, this study found that clinical decision support integrated with a new electronic health record system significantly reduced potentially inappropriate medications.

Overprescribing of opioids to adults by dentists in the U.S., 2011-2015.

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Suda KJ, Zhou J, Rowan SA, et al. Am J Prev Med. 2020;58:473-486.

National guidelines published in 2016 recommend prescribing low-dose opioids for short durations when necessary, including in dentistry practices. This cross-sectional analysis of over 500,000 commercial dental patients over a five-year period (2011-2015) examined prescribing practices prior to the recommendations and found that 29% of prescribed opioids exceeded the recommended dose for management of acute pain and half (53%) exceeded the recommended days’ supply. The authors emphasize the importance of evidence-based interventions tailored to dentistry to curtail excessive opioid prescribing.

A Mistaken Dose of Naloxone 

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WebM&M Case December 18, 2019

A 55-year-old man visited his oncologist for a follow-up appointment after completing chemotherapy and reported feeling well with his abdominal and bony pain well controlled with opioid therapy. At the end of the visit, his oncologist reordered his pain medication and, due to a best practice alert, also prescribed naloxone but failed to provide any instruction on its use. Later that day, the patient took the naloxone along with his opioid pain medication and within a minute experienced severe abdominal and bony pain, requiring admission to the emergency department.

Patient Safety.

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National Pharmacy Association; NPA.

This website for independent community pharmacy owners across the United Kingdom features both free and members-only guidance, reporting platforms, and document templates to support patient safety. It includes reporting tools and incident analysis reports for providers in England, Scotland, and Northern Ireland. Topics covered in the communications include look-alike and sound-alike drugs, patient safety audits, and safe dispensing of liquid medications.

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Cheong V-L, Tomlinson J, Khan S, et al. Prescriber. 2019;30:29-34.

Geriatric patients are particularly vulnerable to medication-related harm. This article summarizes types of incidents and contributing factors to adverse drug events in older patients after hospital discharge. The authors recommend strategies to reduce medication-related harm, including discharge communication improvements, primary care collaboration, and postdischarge patient education.

Using a spare medication vial to store multiple medications: a potentially fatal in-home medication error.

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Leonard JB, Klein-Schwartz W. Ame J Health-syst Pharm. 2019;76:264-265.

Patient and family medication administration mistakes can result in medication errors at home. This commentary describes the problem of "pill dumping," where patients combine their daily medicines into a spare vial. However, patients are at risk for mistakenly taking a vial of a single medication instead of their pill-dump vial and inadvertently overdosing. The authors suggest medication counseling and use of daily pill boxes as tactics to prevent this type of error.

Medication errors in community pharmacies: the need for commitment, transparency, and research.

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Hong K, Hong YD, Cooke CE. Res Social Adm Pharm. 2019;15:823-826.

Medication errors are common in inpatient and ambulatory environments. This commentary summarizes the research exploring the current status of medication safety incident reporting and reduction efforts in community pharmacies. The authors call for community pharmacy corporations to encourage the discussion and data sharing needed to increase transparency around incidents in this care setting. A recent PSNet interview discussed challenges to safety in the retail pharmacy environment.

Evaluation of an electronic dosing calculator to reduce pediatric medication errors.

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Murray B, Streitz MJ, Hilliard M, et al. Clin Pediatr (Phila). 2019;58:413-416.

Pediatric medication dosing is often weight-based and therefore subject to calculation errors. This prospective study demonstrated that use of a clinical decision support tool (a dosing calculator) significantly reduced medication errors.

Effect of a pharmacist-led educational intervention on inappropriate medication prescriptions in older adults: the D-PRESCRIBE randomized clinical trial.

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Martin P, Tamblyn R, Benedetti A, et al. JAMA. 2018;320:1889-1898.

This randomized controlled trial tested a pharmacist-led educational intervention at community pharmacies. Intervention patients received a brochure about potentially inappropriate medications. Discontinuation of potentially harmful medications increased among older adults compared to usual pharmacy care, suggesting that community pharmacies can play a significant role in medication safety.

Medication Safety Dashboard.

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National Health Service.

Data surveillance and transparency are core to measuring and informing improvement efforts. This website provides detailed data that links ambulatory care prescribing activity to National Health Service hospitalizations in an effort to clarify potential adverse medication events. The dashboard launched tracking gastrointestinal bleeding as an indicator of a medication-related adverse result and will expand to other indicators and conditions over time.

Severe hyperglycemia in patients incorrectly using insulin pens at home.

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National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American Society of Health-System Pharmacists. October 12, 2017.

Care devices that enable patients to administer medicines at home can have unintended consequences. This alert raises awareness of hazards related to insulin pen misuse and offers recommendations to reduce risks, such as training patients to properly use pen needles and engaging community pharmacists in verifying that patients understand appropriate administration techniques.

All consumer medication information is not created equal: implications for medication safety.

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Monkman H, Kushniruk AW. Stud Health Technol Inform. 2017;234:233-237.

Medication management in outpatient settings requires patients to recognize adverse medication effects. This expert review study found that standardized information from a large Canadian retail pharmacy lacked key information about possible adverse effects and drug interactions. The authors suggest that this information gap leads to an urgent and addressable patient safety risk.

A Pill Organizing Plight

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WebM&M Case September 1, 2016

An elderly woman with multiple medical conditions experienced new onset dizziness and lightheadedness. A home visit revealed numerous problems with her medications, with discontinued medications remaining in her pillbox and a new prescription that was missing. In addition, on some days she was taking up to five blood pressure pills, when she was supposed to be taking only two.

Hospice diagnosis: polypharmacy—a teachable moment.

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Larson CK, Kao H. JAMA Intern Med. 2015;175:1750-1751.

Overprescribing can increase risk of dementia, particularly among older patients. This commentary describes an incident involving a patient with moderate dementia that worsened when opioids were prescribed following a fall. After a geriatrician evaluated the patient and suspected polypharmacy, the drugs were stopped, caregivers were educated about how to treat the patient, and the patient improved. Highlighting the importance of environmental interventions in treating this patient, the author reviews strategies to address neuropsychiatric symptoms of dementia.

Getting the wrong person's medicine at the pharmacy: easy steps consumers can take to help eliminate these errors.

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ISMP Safe Medicine. July/August 2015;13:1-3.

Dispensing errors in the community setting are a frequent source of concern. This newsletter article describes how correctly completed medication orders can inadvertently be given to the wrong patient in the community pharmacy setting and reviews steps patients can take to avoid receiving the incorrect medication.

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