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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Technology as a Tool for Improving Patient Safety

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Perspective on Safety March 29, 2023

In the past several decades, technological advances have opened new possibilities for improving patient safety. Using technology to digitize healthcare processes has the potential to increase standardization and efficiency of clinical workflows and to reduce errors and cost across all healthcare settings.¹ However, if technological approaches are designed or implemented poorly, the burden on clinicians can increase. For example, overburdened clinicians can experience alert fatigue and fail to respond to notifications. This can lead to more medical errors.

Annual Perspective: Topics in Medication Safety

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Perspective on Safety March 31, 2022

Errors in medication management and administration are major threats to patient safety. This piece explores issues with opioid and nursing-sensitive medication safety as well as medication safety in older adults. Future research directions in medication safety are also discussed.

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...

A qualitative study of prescribing errors among multi-professional prescribers within an e-prescribing system.

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Alshahrani F, Marriott JF, Cox AR. Int J Clin Pharm. 2020;43:884-892.

Computerized provider order entry (CPOE) can prevent prescribing errors, but patient safety threats persist. Based on qualitative interviews with multidisciplinary prescribers, the authors identified several issues related to CPOE interacting within a complex prescribing environment, including alert fatigue, remote prescribing, and default auto-population of dosages.

Pharmacist linkage in care transitions: from academic medical center to community.

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Bloodworth LS, Malinowski SS, Lirette ST, et al. J Am Pharm Assoc . 2019;59:896-904.

Medication reconciliation is one potential strategy for preventing adverse events and readmissions. This study examined a pharmacist-led intervention involving collaborations with inpatient and community-based pharmacists to provide pre-discharge and 30-day medication reconciliation. There were indications that this type of intervention can reduce readmission rates, but further investigation in larger populations is necessary.

Medication Safety in Key Action Areas.

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Geneva, Switzerland: World Health Organization; 2019.

Reducing adverse medication events is a worldwide challenge. This collection of technical reports explores key areas of concern that require action at a system level to improve: high-alert medications, polypharmacy, and medication use at care transitions. Each monograph provides an overview of the topic as well as practical improvement approaches for patients, clinicians, and organizations.

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.

Duplicate Insulin Order

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WebM&M Case March 1, 2019

Seen in the emergency department, a man with insulin-dependent diabetes mellitus had not taken insulin for 3 days. His blood glucose levels were in the 800s with an anion-gap acidosis and positive beta hydroxybutyrate. While awaiting an ICU bed for treatment of diabetic ketoacidosis, the patient received fluids, an insulin drip was started, and blood glucose levels were monitored hourly. When lab results showed he was improving, the team decided to convert his insulin drip to subcutaneous long-acting insulin.

Prospective daily review of discharge medications by pharmacists: effects on measures of safety and efficiency.

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Craynon R, Hager DR, Reed M, et al. Am J Health Syst Pharm. 2018;75:1486-1492.

Pharmacists are expanding their reach as stewards of medication safety into the front line of care. This project report describes the pilot testing of pharmacist involvement in development and review of medication orders in the discharge workflow. A substantive percentage of medication problems were prevented due to pharmacist engagement.

Defining minimum necessary anticoagulation-related communication at discharge: Consensus of the Care Transitions Task Force of the New York State Anticoagulation Coalition.

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Triller D, Myrka A, Gassler J, et al. Jt Comm J Qual Patient Saf. 2018;44:630-640.

Patients prescribed high-risk medications, including anticoagulants, are at increased risk for adverse drug events and may be particularly vulnerable during care transitions. This study describes how a multidisciplinary panel of anticoagulation experts used an iterative consensus-building process to determine what information should be communicated to relevant providers for all patients on anticoagulation undergoing a transition in care.

Quality of handoffs in community pharmacies.

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Abebe E, Stone JA, Lester CA, et al. J Patient Saf. 2021;17:405-411.

Handoffs present a significant patient safety hazard across multiple health care settings. Interruptions and distractions, which can interfere with handoff communication, are prevalent in pharmacy environments. This cross-sectional survey of community pharmacies found that virtually none of the pharmacists had received training in how to hand off information. A significant proportion of responses indicated that pharmacy information technology systems do not support handoff communication. Respondents reported that handoffs are frequently inadequate or inaccurate. The authors conclude that interventions are needed to enhance the quality of handoff communication in community pharmacy settings to prevent dispensing errors.

Discontinued Medications: Are They Really Discontinued?

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WebM&M Case May 1, 2014

An elderly man on warfarin and aspirin for chronic atrial fibrillation and previous cerebrovascular accident presented to the emergency department with a severe headache. Found to have bilateral subdural hematomas and a supratherapeutic INR (4.9), he was admitted to the ICU. Even though the patient was discharged with his warfarin discontinued permanently, the outpatient pharmacy kept it on the active medication list and refilled his mail order prescription automatically, leading again to an elevated INR.

Clostridium Difficile Relapse Secondary to Medication Access Issue

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WebM&M Case April 1, 2014

Following a hospitalization for Clostridium Difficile–associated diarrhea, a woman with HIV/AIDS and B-cell lymphoma was discharged with a prescription for a 14-day course of oral vancomycin solution. At her regular retail pharmacy, she was unable to obtain the medicine, and while awaiting coverage approval, she received no treatment. Her symptoms soon returned, prompting an emergency department visit where she was diagnosed with toxic megacolon.

Implementation of a specialized pharmacy team to monitor high-risk medications during discharge.

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Martin ES, Overstreet RL, Jackson-Khalil LR, et al. Am J Health Syst Pharm. 2013;70:18-21.

This commentary details the development of a medication reconciliation program to improve documentation at discharge, which included identifying high-risk drugs, forming a team of three full-time pharmacists, and tracking patients with pending discharges.

Improving care transitions: current practice and future opportunities for pharmacists.

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Pharmacy AC of C, Hume AL, Kirwin J, et al. Pharmacotherapy. 2012;32:e326-37.

This white paper describes how pharmacists can safeguard medication tracking and communication practices during care transitions.

Developing a programme for medication reconciliation at the time of admission into hospital.

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Manzorro ÁG, Zoni AC, Rieiro CR, et al. Int J Clin Pharm. 2011;33:603-9.

Implementation of an electronic medication reconciliation tool reduced drug discrepancies at the time of hospital admission.

Medication reconciliation during internal hospital transfer and impact of computerized prescriber order entry.

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Lee JY, Leblanc K, Fernandes O, et al. Ann Pharmacother. 2010;44:1887-95.

This study found that 62% of patients transferred between units during a hospitalization had at least one unintentional medication discrepancy. The most common discrepancy was medication omission, independent of which system was used (e.g., paper versus computerized).

ISMP medication error report analysis.

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Cohen MR, Smetzer JL. Hosp Pharm. 2010;45.

This monthly column highlights an initiative to introduce safer device connectors to prevent spinal and epidural medications from being delivered intravenously, discusses the value of independent double-checks, and shares thoughts on the 35th anniversary of this column.

Hospital admission medication reconciliation in medically complex children: an observational study.

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Stone BL, Boehme S, Mundorff MB, et al. Arch Dis Child. 2009.

This study documents the challenges in implementing medication reconciliation in a children's hospital. Five different sources (parents, pharmacies, primary care physicians, discharge summaries, and admission histories) were used to compile admission medication lists, but all were inaccurate to varying degrees, leaving children at high risk of preventable harm.

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