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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 - 17 of 17 Results
Curated Libraries
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...
Carvalho IV, Sousa VM de, Visacri MB, et al. Pediatr Emerg Care. 2021;37:e152-e158.
This study sought to determine the rate of pediatric emergency department (ED) visits due to adverse drug events (ADE). Of 1,708 pediatric patients, 12.3% were admitted to the ED due to ADEs, with the highest rates of admission due to neurological, dermatological, and respiratory medications. The authors recommend the involvement of clinical pharmacists to prevent and identify ADEs in the pediatric population, particularly through education of children’s caregivers and health professionals.
Agarwal M, Lovegrove MC, Geller RJ, et al. J Pediatr. 2020;219.
Parents are advised to keep medications inaccessible to young children to avoid accidental ingestions. This study prospectively enrolled nearly 4,500 individuals calling poison control centers about unsupervised solid dose medication exposure in young children (ages 5 years and younger) to identify the types of containers from which young children accessed these medications. The majority of incidents (71.6%) involved children 2 years and younger. Incidents were equally divided among calls involving prescription-only medications, over-the-counter (OTC) projects requiring child-resistant packaging, and OTC projects not requiring such packaging. One-third of all incidents involved medication that had been removed from the original container; this was more likely in incidents involving prescription drugs compared to OTC drugs (adjusted odds ratio, 3.39; 95% CI, 2.87-4.00).  These findings suggest that unsupervised medication exposures in young children are just as often the result of adults removing medications from original packaging as the result of improper use or failure of child-resistant packaging.
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.
Jalal H, Buchanich JM, Roberts MS, et al. Science (1979). 2018;361.
Opioid overdose deaths remain a threat to patient safety. Information about how overdose deaths are nationally distributed is critical to inform prevention efforts. This robust analysis examined all drug overdose deaths in the United States over a 38-year period. Drug overdoses began increasing exponentially long before the opioid prescribing boom in the mid-1990s and continue to rise in this way. Demographically distinct subepidemics of prescription opioid, synthetic opioid, and stimulant use all contribute to drug overdose deaths as a whole. The authors speculate about what factors other than opioid prescribing might drive escalating substance use-related deaths. An Annual Perspective and a PSNet perspective provide further insights into how safety efforts can reduce opioid-related harm.
Meyer-Massetti C, Meier CR, Guglielmo J. Int J Clin Pharm. 2018;40:325-334.
The incidence of preventable adverse events in patients receiving home care has been found to be comparable to hospitalized patients. This review sought to characterize medication errors in home care patients and found that the most common type of medication error was the prescribing of potentially inappropriate medications to elderly patients.
Mack JW, Jacobson J, Frank D, et al. Jt Comm J Qual Patient Saf. 2017;43:498-507.
Previous research has established that patient complaints can shed light on patient safety concerns. This analysis of 266 patient complaints in cancer care found that more than 40% were interpersonal in nature, whereas 11% were related to quality and safety. The authors suggest ongoing, systematic analysis of patient complaints in order to identify suboptimal care.
Parand A, Faiella G, Franklin BD, et al. Ergonomics. 2018;61:104-121.
Informal caregivers can make errors in administering medications to patients in home settings. This human factors analysis identified multiple vulnerabilities, including incorrect dosing, storage, timing, and failure to discontinue medications as instructed. The authors note an overall lack of support and communication for caregiver-administered medications in home and community settings.
Yin S, Parker RM, Sanders LM, et al. Pediatrics. 2017;140:e20163237.
Inaccurate dosing of liquid medications for pediatric patients is known to contribute to medication errors. In this randomized controlled trial, parents of children younger than 9 were able to demonstrate a correct liquid medication dose when they received a dosing tool, such as a syringe, that corresponded more closely to the prescribed medication volume. Directions that include a picture were more likely to lead to accurate dosing compared to text-only instructions. This study adds to prior research demonstrating the need for literacy-friendly medication instructions, especially for dosing of liquid medications to children. Two of the coauthors, Michael S. Wolf and Stacy C. Bailey, described the implications of limited health literacy on patient safety in a past PSNet perspective.
Harris LM, Dreyer BP, Mendelsohn AL, et al. Acad Pediatr. 2017;17:403-410.
Correctly dosing liquid medications for children can be challenging for caregivers with limited health literacy. This cross-sectional analysis found that parents with limited English proficiency and health literacy were more likely to make dosing errors with liquid medications. These results affirm the need to redesign medication labels and dosing aids to promote safe use.
Walsh KE, Bacic J, Phillips BD, et al. J Patient Saf. 2021;17:e177-e185.
This study sought to improve safe at-home pediatric medication administration through an interactive voice response intervention. Researchers found that medication dosing errors and nonadherence were common. The intervention increased medication communication but did not make parents more likely to bring medications to a physician visit as recommended. This study highlights the challenges of safe medication management for outpatients.
Parand A, Garfield S, Vincent C, et al. PLoS One. 2016;11:e0167204.
Medication administration errors have been studied primarily in the hospital environment. Less is known about the types of errors that may occur in the home setting and the role caregivers play in this context. This narrative systematic review found caregiver medication administration error rates ranging from 1.9% to 33% of all medications administered, highlighting a potential threat to patient safety.
Manias E. Health Expect. 2015;18:850-66.
Polypharmacy, or taking multiple medications, is a risk factor for adverse drug events. This interview study examined how family members participated in medication management for hospitalized patients taking five or more medications and found that communication between family members and health care professionals was insufficient. The authors advocate for providers to proactively engage in discussions with family members as they can know important information regarding patients' medications.
Southwick FS, Cranley NM, Hallisy JA. BMJ Qual Saf. 2015;24:620-9.
This study analyzed data from an internet-based reporting system that enabled patients and families to describe adverse events. Respondents reported missed and delayed diagnoses, treatment errors, procedural complications, health care–associated infections, and adverse drug events. Most participants did not experience prompt error disclosure but instead faced a denial of responsibility and secretive behavior, which they related to subsequent mistrust. To prevent adverse events, patients and family members suggested using systems approaches (such as universal handwashing and other infection control measures), improving care transitions between providers, ensuring supervision of trainees, and partnering with patients and families for shared decision-making. These findings underscore the importance of error disclosure, effective communication, and allowing patients to report adverse events in order to enhance safety.
Benjamin JM, Cox ED, Trapskin PJ, et al. Pediatrics. 2015;135:94-101.
This observational study found that more than half of parents of hospitalized children initiated conversations about medications during family-centered rounds. Common topics included scheduling (i.e., frequency or duration) or adverse drug reactions. These results underscore the importance of patient engagement in medication use and safety.
Riley-Lawless K. J Spec Pediatr Nurs. 2009;14:94-101.
Medication reconciliation continues to be a challenging endeavor for health care systems since being elevated to a National Patient Safety Goal. This study surveyed 100 families and found that they are frequently unable to provide complete medication information about their children due to a number of highlighted barriers.