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.
Keers RN, Plácido M, Bennett K, et al. PLoS One. 2018;13:e0206233.
This interview study used a human factors method, the critical incident technique, to identify underlying factors in medication administration errors in a mental health inpatient facility. The team identified multiple interconnected vulnerabilities, including inadequate staffing, interruptions, and communication challenges. The findings underscore the persistence of widely documented medication safety administration concerns.
Hemingway S, McCann T, Baxter H, et al. Int J Nurs Pract. 2015;21:733-40.
Medication errors are common in mental health care. This survey of nurses and nursing students identified interruptions and insufficient medication knowledge as major barriers to ensuring medication safety in outpatient mental health.
Kelly T, Roper C, Elsom S, et al. Int J Ment Health Nurs. 2011;20:371-9.
This qualitative study demonstrated marked similarities between nurse and consumer perspectives for safe patient identification. Technical aids, such as wristbands and photographs, were deemed important but not replacements for the nurse–patient encounter.
Sawamura K, Ito H, Yamazumi S, et al. Psychiatry Clin Neurosci. 2005;59:379-84.
The authors analyzed incident reports from Japanese long-term care psychiatric units to understand the relationship between environmental, organizational, and human factors elements of drug administration and how they affect the interception of errors.
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