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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 242 Results
Iturgoyen Fuentes DP, Meneses Mangas C, Cuervas Mons Vendrell M. Eur J Hosp Pharm. 2022;Epub Sep 30.
Medication reconciliation at hospital admission has reduced medication errors, but less is known about the pediatric population, particularly which patients may benefit most from reconciliation. This retrospective study of pediatric patients who experienced at least one medication reconciliation error found children older than 5 years, taking 4 or more medications, or with neurological or onco-hematological conditions were at increased risk of errors. Prioritization of these populations may improve the effectiveness of medication reconciliation.
Laing L, Salema N-E, Jeffries M, et al. PLoS ONE. 2022;17:e0275633.
Previous research found that the pharmacist-led IT-based intervention to reduce clinically important medication errors (PINCER) can reduce prescription and medication monitoring errors. This qualitative study explored patients’ perceived acceptability of the PINCER intervention in primary care. Overall perceptions were positive, but participants noted that PINCER acceptability can be improved through enhanced patient-pharmacist relationships, consistent delivery of PINCER-related care, and synchronization of medication reviews with prescription renewals.
Beerlage-Davids CJ, Ponjee GHM, Vanhommerig JW, et al. Int J Clin Pharm. 2022;Epub Oct 15.
Older adults taking multiple medications are at increased risk for adverse drug events following hospital discharge. In this study, patients were contacted two weeks after hospital discharge to evaluate adverse events, adverse drug events, and health-related quality of life (HRQoL). There was a weak but significant correlation between patient-reported adverse events and HRQoL, but not patient-reported adverse drug events.  
Punj E, Collins A, Agravedi N, et al. Pharmacol Res Perspect. 2022;10:e01007.
Pharmacists play an important role in preventing medication errors. This systematic review identified 17 studies showing that pharmacy teams working in acute or emergency medicine departments can reduce medication errors through medication reconciliation.
Sacarny A, Safran E, Steffel M, et al. JAMA Health Forum. 2022;3:e223378.
Concurrent prescribing of opioids and benzodiazepines can put patients at increased risk of overdose. This randomized study found that pharmacist email alerts to clinicians caring for patients recently co-prescribed opioids and benzodiazepines did not reduce concurrent prescribing of these medications.
Thiruchelvam K, Byles J, Hasan SS, et al. Res Social Adm Pharm. 2022;18:3758-3765.
Potentially inappropriate medications (PIMs) are common among older adults living in residential care facilities. This study examined the impact of the Australian Residential Medication Management Review (RMMR) service (a patient-centered medication review program) on PIM prescribing among older women living in residential aged care facilities. Researchers identified no evidence of an association between the medication review program and use of PIMs in the following year.

Schnipper JL. Ann Intern Med. 2022;175(8):ho2-ho3.

Medication reconciliation is a primary method for improving the safety of medication administration in acute care. This essay highlights how individual hospitalists can improve medication reconciliation both at the practice and organizational level. Areas of influence discussed include medication history completeness and health information technology design.
McKay C, Schenkat D, Murphy K, et al. Hosp Pharm. 2022;Epub Jun 4.
Insulin is a high-alert medication due to heightened risk for serious patient harm if administered incorrectly. This review presents types of common errors (e.g., wrong patient, cross-contamination), pros and cons of potential dispensing strategies, and the impact of organizational factors (e.g., workflows, cost) on safe dispensing. Additionally, the authors make recommendations for dispensing, taking organization factors into account.
Klopotowska JE, Kuks PFM, Wierenga PC, et al. BMC Geriatr. 2022;22:505.
Adverse drug events (ADE) are common and preventable. In this study, hospital pharmacists met face-to-face with prescribing residents to review medications ordered for older adult inpatients. Preventable and unrecognized ADE decreased following implementation. The most common preventable ADE both before and after implementation occurred during the prescribing stage.
Jessurun JG, Hunfeld NGM, Van Rosmalen J, et al. J Patient Saf. 2022;Epub Jun 30.
Intravenous admixture preparation errors (IAPE) in hospitals are common and may result in harm if they reach the patient. In this before-and-after study, IAPE data were collected to evaluate the safety of a pharmacy-based centralized intravenous admixture service (CIVAS). Compared to the initial standard practice (nurse preparation on the ward), IAPE of all severity levels (i.e., potential error, no harm, harm) decreased and there were no errors in the highest severity level after implementation of CIVAS.
WebM&M Case August 5, 2022

This WebM&M highlights two cases where home diabetes medications were not reviewed during medication reconciliation and the preventable harm that could have occurred. The commentary discusses the importance of medication reconciliation, how to compile the ‘best possible medication history’, and how pharmacy staff roles and responsibilities can reduce medication errors.

Levkovich BJ, Orosz J, Bingham G, et al. BMJ Qual Saf. 2022;Epub Jul 5.
Rapid response teams, also known as medical emergency teams (MET), are activated when a patient demonstrates signs of clinical deterioration to prevent transfer to intensive care, cardiac arrest, and death. MET activations were prospectively reviewed at two Australian hospitals to determine the proportion of activations due to medication-related harms and assess the preventability of the activation. 23% of MET activations were medication-related, and 63% of those were considered preventable. Most preventable activations were patients with hypertension, and prevention strategies should focus on these patients.
Jordan M, Young-Whitford M, Mullan J, et al. Aust J Gen Pract. 2022;51:521-528.
Interventions such as deprescribing, pharmacist involvement, and medication reconciliation are used to reduce polypharmacy and use of high-risk medications such as opioids. In this study, a pharmacist was embedded in general practice to support medication management of high-risk patients. This study presents perspectives of the pharmacists, general practitioners, practice personnel, patients, and carers who participated in the program.
Gleeson LL, Ludlow A, Wallace E, et al. Explor Res Clin Soc Pharm. 2022;6:100143.
Primary care rapidly shifted to telehealth and virtual visits at the start of the COVID-19 pandemic. This study asked general practitioners (GPs) and pharmacists in Ireland about the impact of technology (i.e., virtual visits, electronic prescribing) on medication safety since the pandemic began. Both groups identified electronic prescribing as the most significant workflow change. GPs did not perceive a change in medication safety incidents due to electronic prescribing; pharmacists reported a slight increase in incidents.

Clark C. MedPage Today. June 2, 2022

Transparency and discussion of errors is a hallmark of the culture needed to improve safety. This article summarizes an Anesthesia Patient Safety Foundation statement directing organizations and individuals that provide anesthesia care to protect patients and encourage learning from error. It provides context through a discussion of official reports and investigations of a high-profile incident that culminated in criminal charges for the clinician involved.
Jambon J, Choukroun C, Roux-Marson C, et al. Clin Neuropharmacol. 2022;45:65-71.
Polypharmacy in older adults is an ongoing safety concern due to the risk of being prescribed a potentially inappropriate medication or co-prescription of medications with dangerous interactions. In this study of adults aged 65 and older with chronic pain, 54% were taking at least one potentially inappropriate medication and 43% were at moderate or high risk of adverse drug events. Measures such as involvement of a pharmacist in medication review could reduce risk of adverse drug events in older adult outpatients.
Perspective on Safety March 31, 2022

Errors in medication management and administration are major threats to patient safety. This piece explores issues with opioid and nursing-sensitive medication safety as well as medication safety in older adults. Future research directions in medication safety are also discussed.

Kukielka E, Jones R. Patient Safety. 2022;4:49-59.
Medication errors can occur in all clinical settings, but can have especially devastating results in emergency departments (EDs). Between January 1, 2011, and December 31, 2020, 250 serious medication errors occurring in the ED were reported to the Pennsylvania Patient Safety Reporting System. Errors were more likely to occur on weekends and between 12:00 pm and midnight; patients were more likely to be women. Potential strategies to reduce serious medication errors (e.g., inclusion of emergency medicine pharmacists in patient care) are discussed.

March KL, Peters MJ, Finch CK, et al. J Pharm Pract. 2022;35(1):86-93.

Transitions of care from inpatient to outpatient settings are vulnerable to medication errors. This study found that patients receiving pharmacist-led medication reconciliation and education prior to discharge reported higher patient satisfaction scores; lower readmission rates compared to standard care patients were also observed. Pharmacists potentially prevented 143 medication safety events during medication reconciliation.