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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 - 20 of 22 Results
May 4, 2023
The implementation of effective patient safety initiatives is challenging due to the complexity of the health care environment. This curated library shares resources summarizing overarching ideas and strategies that can aid in successful program execution, establishment, and sustainability.
Curated Libraries
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.
Mahomedradja RF, van den Beukel TO, van den Bos M, et al. BMC Emerg Med. 2022;22:35.
The potential for medication errors may increase due to redeployment and reorganization of hospital resources during COVID-19 surges. In this study of patients hospitalized during the first wave of the pandemic, over 90% had at least one prescribing error three months after hospitalization. Intensive care unit admission and a history of chronic obstructive pulmonary disease (COPD) or asthma were risk factors for prescribing errors. Acknowledging and understanding these risk factors allows hospital leadership to target interventions for this population.
Andersen TS, Gemmer MN, Sejberg HRC, et al. Pharmaceuticals (Basel). 2022;15:142.
Conducting a complete medication reconciliation in the emergency department may be difficult or even impossible if the patient is unable to speak for themselves. In these instances, clinicians must rely solely on electronic records of medication prescriptions, which do not always reflect the medications being taken. This analysis of prescriptions entered into the Danish Shared Medication Record (SMR) and patient reports of medications taken showed 81% of patients had at least one discrepancy, the most common of which was discontinued medications still showing in the SMR.
Bourne RS, Jennings JK, Panagioti M, et al. BMJ Qual Saf. 2022;31:609-622.
Patients transferring from the intensive care unit (ICU) to the hospital ward may experience medication errors. This systematic review examined medication-related interventions on the impact of medication errors in ICU patients transferring to the hospital ward. Seventeen studies were included with five identified intervention components. Multi-component studies based on staff education and guidelines were effective at achieving almost four times more deprescribing on inappropriate medications by the time of discharge. Recommendations for improving transfers are included.
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...
Parro Martín M de los Á, Muñoz García M, Delgado Silveira E, et al. J Eval Clin Pract. 2021;27:160-166.
Researchers analyzed medication errors occurring in the trauma service of a single university hospital in Spain to inform the development and implementation of a set of measures to improve the safety of the pharmacotherapeutic process. The Multidisciplinary Hospital Safety Group proposed improvement measures that intend to involve pharmacists in medication reconciliation, increase the use of medication reconciliation in the emergency and trauma departments, and incorporate protocols and alerts into the electronic prescribing system.
Aldawood F, Kazzaz Y, AlShehri A, et al. BMJ Open Qual. 2020;9.
This study reports on results of completing TeamSTEPPS training by leadership and staff in the pediatric intensive care unit (PICU) at one hospital in Saudi Arabia. The team implemented a daily safety huddle aimed at improving communication and early identification and timely resolution of patient safety issues. Over a 7-month period, 340 safety issues were addressed; the majority involved infection control and medication errors (32%), communication issues (24%) and documentation issues (17%). The authors observed that the daily huddle addressed misconceptions and misunderstandings between nursing and medical teams leading to improved care delivery.
Mackay E, Jennings J, Webber S. BJA Edu. 2019;19:151-157.
Human factors affect medication delivery in the operating room. This review highlights the role of the anesthesiologist in safe medication administration and recommends strategies to reduce opportunities for error at each stage of medication administration, such as preoperative time-outs, preparation of medicines with color-coded syringe labels, patient identification prior to medication administration, and review of medications at handovers after administration.
Moore P, Armitage G, Wright J, et al. J Patient Saf. 2011;7:148-154.
Achieving medication reconciliation continues to present significant challenges, despite existing guidelines and its demonstrated impact on patient safety. Electronic health records (EHRs) and related tools have long been touted as solutions to bolster reconciliation safety. This study evaluated whether an EHR shared between outpatient and inpatient providers could reduce suspected medication discrepancies. Although errors were reduced, significant discrepancies persisted among various forms of reconciliation, including differences between what was in the record and what patients actually reported taking. Problems included outdated or incomplete medication information, incorrect information provided by patients, or mismatched information between the different sources. The authors argue that EHRs, as an added information vehicle, may help reduce reconciliation errors, but they caution that EHRs are only a tool (and not in themselves a solution) for safer reconciliation. A past AHRQ WebM&M commentary discussed whose job it is to assure safe medication reconciliation.
Grimes TC, Duggan CA, Delaney TP, et al. Br J Clin Pharmacol. 2011;71:449-57.
Medication errors at hospital discharge remain a persistent problem, as no consensus exists on the best method of medication reconciliation. This study analyzed the patient- and medication-specific factors associated with medication reconciliation discrepancies upon discharge from two Irish hospitals.
De Winter S, Spriet I, Indevuyst C, et al. Qual Saf Health Care. 2010;19:371-5.
Pharmacists and physicians obtained different medication histories in the majority of patients presenting to an urban emergency department, with physicians frequently committing errors of omission by failing to record patients' use of as-needed medications.
Armitage G, Newell R, Wright J. J Eval Clin Pract. 2010;16:1189-97.
This analysis of voluntarily reported medication errors found that the reports often did not yield useful data. The authors make suggestions, based on error theory, to improve reporting systems to enhance the ease of reporting and the quality of error reports.
Frey B, Ersch J, Bernet V, et al. Qual Saf Health Care. 2009;18:446-9.
Parents of hospitalized children feel personally responsible for their children's safety, and efforts are being made to engage parents in safety efforts. This retrospective review of incident reports found more than 100 cases in a 5-year period in which parents were directly involved in adverse events in a pediatric intensive care unit. These included cases where parents detected an adverse event as well as cases where the parents caused the adverse event (for example, by accidentally disconnecting equipment). The authors advocate for development of a safety culture that encourages parents to report concerns, a goal that is a major focus of the Josie King Foundation.
Valentin A, Capuzzo M, Guidet B, et al. BMJ. 2009;338:b814.
Intensive care unit (ICU) patients are generally considered to be at increased risk for medication errors. This cross-sectional study, conducted at hospitals in 27 countries, fused voluntary error reports to attempt to quantify the risk associated with intravenous medications in ICU patients. The authors found an error rate of 74.5 per 100 patient-days, with approximately 1% of patients suffering death or permanent harm as a result of a medication error. Most errors occurred during drug administration. Prior research has demonstrated the effectiveness of clinical pharmacists at reducing medication errors in the ICU.
Campbell AJ, Bloomfield R, Noble DW. Anaesthesia. 2006;61:1087-92.
This study found that nearly 20% of patients had their outpatient medications discontinued at the time of intensive care unit admission and not restarted at hospital discharge, without adequate documentation of a clinical indication. These findings are similar to those of a prior study.