Skip to main content

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.

Search All Content

Search Tips
Save
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Narrow Results By
PSNet Original Content
Commonly Searched Resource Types
Displaying 1 - 18 of 18 Results
Burfeind KG, Zarnegarnia Y, Tekkali P, et al. Anesth Analg. 2022;135:1048-1056.
The American Geriatrics Society (AGS) Beers Criteria serves as a guideline for prescribers to avoid potentially inappropriate medications (PIM) in geriatric patients (age 65 years and older). In this retrospective cohort study, nearly 70% of geriatric patients undergoing elective surgery received at least one PIM identified by the Beers Criteria. Patients, including cognitively impaired and frail patients, who received at least one PIM, had longer length of hospital stay after surgery.
Lambert BL, Schiff GD. J Am Coll Clin Pharm. 2022;5:981-987.
In the wake of the criminal conviction of a nurse involved in a medical error, numerous organizations and institutions have warned of the negative impact it could have on learning and error disclosure. This commentary presents strategies to reduce the risk of criminal prosecution for pharmacists, including education of prosecutors and expert witnesses and minimization of overrides and workarounds.
Reese T, Wright A, Liu S, et al. Am J Health Syst Pharm. 2022;79:1086-1095.
Computerized decision support alerts for drug-drug interactions are commonly overridden by clinicians. This study examined fifteen well-known drug-drug interactions and identified risk factors that could reduce risk in the majority of interactions (e.g., medication order timing, medication dose, and patient factors).
Shah AS, Hollingsworth EK, Shotwell MS, et al. J Am Geriatr Soc. 2022;70:1180-1189.
Medication reconciliations, including conducting a best possible medication history (BPMH), may occur multiple times during a hospital stay, especially at admission and discharge. By conducting BPMH analysis of 372 hospitalized older adults taking at least 5 medications at admission, researchers found that nearly 90% had at least one discrepancy. Lower age, total prehospital medication count, and admission from a non-home setting were statistically associated with more discrepancies.
Ebbens MM, Gombert-Handoko KB, Wesselink EJ, et al. J Am Med Dir Assoc. 2021;22:2553-2558.e1.
Medication reconciliation has been shown to reduce medication errors but is a time-consuming process. This study compared medication reconciliation via a patient portal with those performed by a pharmacy technician (usual care). Medication discrepancies were similar between both groups, and patients were satisfied using the patient portal, which saved 6.8 minutes per patient compared with usual care.
Breuker C, Macioce V, Mura T, et al. J Patient Saf. 2021;17:e645-e652.
In this prospective observational study, hospital pharmacy staff obtained the best possible medication history for adult patients at admission to and discharge from one French hospital. Unintended medication discrepancies were identified in nearly 30% of patients. Most medication errors were omissions and risk of error increased with the number of medications.
Maxwell E, Amerine J, Carlton G, et al. Am J Health Syst Pharm. 2021;78:s88-s94.
Clinical decision support (CDS) tools are intended to enhance care decision and delivery processes. This single-site retrospective study evaluated whether a CDS tool can reduce discharge prescription errors for patients receiving a medication substitution at admission. Findings indicate that use of CDS did not result in a decrease in discharge prescription omissions, duplications, or inappropriate medication reconciliation.
Stuijt CCM, Bekker CL, van den Bemt BJF, et al. Res Social Adm Pharm. 2021;17:1426-1432.
This multicenter prospective study explored the effect of medication reconciliation on patient-reported, potential adverse events post-discharge. Although the intervention – which consisted of a pharmacy team providing patient both education and medication review upon admission and discharge as well as information transfer to primary care – did not decrease the proportion of patients with adverse events, it did reduce the number of potential adverse events.
Watterson TL, Stone JA, Brown RL, et al. J Am Med Inform Assoc. 2021;28:1526-1533.
Prior research has found that ambulatory electronic health records cannot communicate medication discontinuation instructions to pharmacies. In this study, the implementation of the CancelRx system led to a significant, sustained increase in successful medication discontinuations and reduced the time between medication discontinuation in the clinic EHR and pharmacy dispensing software.
Kabir R, Liaw S, Cerise J, et al. J Pharm Pract. 2021:089719002110212.
The best possible medication history (BPMH) is the gold standard of medication reconciliation of a patient’s prescribed and over-the-counter medications. In this study, Certified Pharmacy Technicians (CPhTs) obtained BPMH from patients admitted through the emergency department. In Quality Assurance reviews, the CPhTs identified medication discrepancies at a similar rate to pharmacists, indicating that CPhTs may be a cost-effective alternative to pharmacists in obtaining BPMH.
Cattaneo D, Pasina L, Maggioni AP, et al. Drugs Aging. 2021;38:341-346.
Older adults are at increased risk of hospitalization due to COVID-19 infections. This study examined the potential severe drug-drug interactions (DDI) among hospitalized older adults taking two or more medications at admission and discharge. There was a significant increase in prescription of proton pump inhibitors and heparins from admission to discharge. Clinical decision support systems should be used to assess potential DDI with particular attention paid to the risk of bleeding complications linked to heparin-based DDIs.
Krukas A, Franklin ES, Bonk C, et al. Patient Safety. 2020;2.
Intravenous vancomycin is an antibiotic with known medication safety risk factors. This assessment is designed to assist organizations to review clinician and organizational knowledge, medication administration activities and health information technology as a risk management strategy to minimize hazards associated with vancomycin use. 
Erickson SR, Kamdar N, Wu C-H. Am J Intellect Dev Disabil. 2019;125:37-48.
Prior research has found that children with intellectual or developmental disabilities (IDD) may experience poor quality care and are at risk for adverse events, but less is known about risk among adults with IDD. Using data from a nationally representative database, the authors compared hospitalizations due to adverse medication events among adults with IDD compared with the general adult population and found that adults with IDD were at a significantly greater risk of having a hospital admission due to an adverse event (odds ratio, 1.28).
Kennedy AR, Massey LR. Am J Health Syst Pharm. 2019;76:1481-1491.
This Special Feature discusses risks and vulnerabilities around medications in non-pediatric hospitals that provide care to pediatric patients. The authors identify risks and provide recommendations to ensure safe care of children including optimizing technology, utilizing external resources, and ensuring a pediatric pharmacist is in place.
Frid S, Zapico V, Mansilla A, et al. Stud Health Technol Inform. 2019;264:581-585.
Clinical provider order entry (CPOE) and clinical decision support systems  (CDSS) are intended to enhance medication safety by reducing errors associated with prescription drugs. This study evaluated a tool allowing pharmacists to record errors or near misses, such as medication omission or unjustified medication stops, and communicate those events to the provider. Although only 29% of physicians accepted the pharmacist’s recommendations, these communicated events led to the provider following 112 recommended changes, which was an acceptance rate of 58%.   
Parker H, Farrell O, Bethune R, et al. Br J Clin Pharmacol. 2019;85:2405-2413.
Despite process changes and availability of new technologies, prescribing errors (one type of medication administration errors) remain a serious safety problem. This article describes a single-site pharmacist-led intervention that involved doctors-in-training (residents) reviewing video footage of their patient visits with a pharmacist. The feedback intervention resulted in a significant reduction in prescribing errors and was found acceptable and feasible by participants. 
Jennings HR, Miller EC, Williams TS, et al. Jt Comm J Qual Patient Saf. 2008;34:196-200.
Hospitalized patients receiving anticoagulants such as warfarin are at high risk for adverse drug events, and reducing the incidence of such errors is one of the Joint Commission's 2008 National Patient Safety Goals. In this study, a hospital system instituted several patient safety measures, including an anticoagulation service and executive walk rounds, to target anticoagulant-related medication errors. The 3-year project resulted in a significant reduction in both bleeding and thrombotic episodes. A case of a warfarin-related adverse event is discussed in an AHRQ WebM&M commentary.
Picone DM, Titler MG, Dochterman J, et al. Am J Med Qual. 2008;23:115-127.
The vast majority of medication errors among geriatric patients at a university hospital were preventable. Factors predicting medication errors included patient factors, medication factors (i.e., polypharmacy), and systems factors (i.e., nurse staffing changes).