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 32 Results

Medication guides: patient medication information. A proposed rule by the Food and Drug Administration.

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May 31, 2023; Fed Register;88:35694-35728.

Standardized medication labels have been shown to increase patient comprehension and adherence. The Food and Drug Administration (FDA) is proposing a rule which, if approved, would require an easily understandable, one-page medication guide be given to patients when receiving medication in the outpatient setting. The comments submission period is now closed.

ISMP Survey on the 2022-2023 Targeted Medication Safety Best Practices for Hospitals.

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Institute for Safe Medication Practices. May 2023.

The integration of best practices into daily work is an indication of their usefulness and sustainability. This survey seeks to understand the broad use of 2022-2023 Targeted Medication Safety Best Practices for Hospitals throughout health care to determine implementation successes and barriers. Data submission closes June 30, 2023.

Challenge Competition: Impact of Patient Safety Tools.

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Agency for Healthcare Research and Quality, Rockville, MD. 2023.

The Agency for Healthcare Research and Quality (AHRQ) offers many practical tools and resources to help healthcare organizations, providers, and others make patient care safer These tools are based on research, and they can assist staff in hospitals, emergency departments, long-term care facilities, and ambulatory settings to prevent avoidable complications of care. The purpose of this challenge is to elicit new narratives of how AHRQ toolkits are being used. Up to ten winners will receive $10,000 each. Submissions are due October 27, 2023.

ISMP survey on tall man (mixed case) lettering to reduce drug name confusion.

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Institute for Safe Medication Practices.

Mixed case letters are one suggested strategy to reduce look-alike medication name errors. This survey announcement calls for insight from the field to update an existing resource of problematic drug name pairs and examine the effectiveness of mixed case letter use to minimize confusion. The comment submission period is now closed.

Golden State Medical Supply, Inc. Issues a Voluntary Nationwide Recall of Atenolol 25 mg Tablets and Clopidogrel 75 mg Tablets Due to a Label Mix-up.

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MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; September 29, 2022.

Recalls of medications due to labeling errors are an established approach to minimize the potential for harm. This announcement highlights a labeling mistake with hypertension and antiplatelet medications that could result in dose omissions or bleeding risk.

Meitheal Pharmaceuticals, Inc. issues voluntary nationwide recall of Cisatracurium Besylate Injection, USP 10mg per 5mL due to mislabeling.

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MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 27, 2021.

Labeling mistakes in the pharmaceutical production cycle can remain undetected until the affected medication reaches a patient. This alert reports a recall of a neuromuscular blocker for use in surgery due to it being mislabeled as a medication to increase blood pressure.

FDA advises health care professionals and patients about insulin pen packaging and dispensing.

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MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; October 13, 2020.

Insulin use errors are common despite their heightened potential for patient harm. This announcement highlights labeling and storage practices to reduce dispensing and administration errors associated with individual insulin pen use.

FDA alerts health care professionals to the temporary absence of warning statement on the vial caps of two neuromuscular blocking agents.

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MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration. June 2, 2020.

Neuromuscular blocking agents are high alert medications that can severely harm patients if used incorrectly. This announcement alerts clinicians to the absence of warning statements on two types of paralyzing agents, as well as to steps to minimize mistaken use.

Differences in strength expression on product labels of compounders and conventional manufacturers may lead to dosing errors.

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US Food and Drug Administration; FDA.

Confusing labeling can affect safe medication preparation and administration. This safety announcement reviews case reports associated with inconsistent drug strength information that contributed to dosing errors of compounded injectable products.

Safe handling of concentrated electrolyte products from outsourcing facilities during critical drug shortages.

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National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American Society of Health-System Pharmacists. May 24, 2018.

Drug shortages can necessitate hospitals to find alternative sources for important medications. This alert raises awareness of risks associated with potassium chloride use due to variations in labeling, packaging, or concentration of outsourced medications. Recommendations include use of barcode scanning and communicating with staff regarding drug shortages.

FDA Drug Safety Communication: FDA requires labeling changes for prescription opioid cough and cold medicines to limit their use to adults 18 years and older.

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MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 11, 2018.

Addressing the opioid epidemic has necessitated new approaches to prevent opioid misuse. This announcement describes new FDA requirements regarding labeling changes for prescription cough and cold medicines containing codeine or hydrocodone in pediatric patients.

FDA Drug Safety Communication: FDA cautions about dosing errors when switching between different oral formulations of antifungal Noxafil (posaconazole); label changes approved.

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US Food and Drug Administration; FDA.

This announcement alerts prescribers to differences in two oral formulations of the same medication that can lead to dosing errors. The FDA suggests that clinicians specify dosage form, strength, and frequency on prescriptions for this drug to reduce the risk of patient harm and recommend that pharmacists follow up with prescribers if such information is missing.

FDA Drug Safety Communication: FDA warns about prescribing and dispensing errors resulting from brand name confusion with antidepressant Brintellix (vortioxetine) and antiplatelet Brilinta (ticagrelor).

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MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; July 30, 2015.

Look-alike and sound-alike drug names can contribute to confusion and result in medication errors. To raise awareness of potential wrong-patient errors due to similarity between two proprietary names, this announcement describes near misses with the drugs at the prescribing and dispensing stage and suggests clinicians use the generic names for the medications to reduce risk of patient harm.

Fentanyl transdermal system (marketed as Duragesic) information.

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US Food and Drug Administration. MedWatch. July 10, 2015.

This Food and Drug Administration resource alerts health care professionals, patients, and their caregivers to the possibility for overdoses of fentanyl in patients using fentanyl skin patches for pain control.

Potentially dangerous confusion between Bloxiverz (neostigmine) injection and Vazculep (phenylephrine) injection.

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National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American Society of Health-System Pharmacists. March 23, 2015

Misunderstanding prescription drug labels is a recognized source of errors in ambulatory care. This announcement raises awareness of new packaging for existing medications that may cause confusion due to similarities in color and layout. Recommendations are outlined to prevent mistakes associated with use of these medications.

FDA requires label warnings to prohibit sharing of multi-dose diabetes pen devices among patients.

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FDA Safety Communication. Silver Spring, MD: US Food and Drug Administration; February 25, 2015.

The practice of using multi-dose insulin pens, meant for single patient use only, among multiple patients has been linked to health care–associated infections. This announcement outlines federal labeling requirements to raise awareness of the risks associated with this practice to prevent misuse of the devices.

Potential inaccuracy of electronically transmitted medication history information used for medication reconciliation.

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National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American Society of Health-System Pharmacists. February 18, 2014.

This announcement describes concerns related to incorrect information provided by a medication history service. Providers using Surescripts are encouraged to investigate and confirm medication dosages in electronic medical records that seem inappropriate.

Important change to heparin container labels to clearly state the total drug strength.

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MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; December 6, 2012.

This announcement describes a labeling change designed to prevent calculation errors associated with heparin, a high-alert medication.

2012 ISMP International Medication Safety Self Assessment for Oncology.

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Institute for Safe Medication Practices and Institute for Safe Medication Practices Canada.

This tool evaluates the safety of cancer treatment delivery in hospitals and ambulatory care settings.

Medication errors resulting from confusion between risperidone (Risperdal) and ropinirole (Requip).

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MedWatch Safety Alert, FDA Drug Safety Communication. Silver Spring, MD: US Food and Drug Administration; June 13, 2011.

This notice raises awareness of a two look-alike/sound-alike drugs, one an antipsychotic medication and the other a dopamine agonist.

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