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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 21 Results
Short A, McPeake J, Andonovic M, et al. Eur J Hosp Pharm. 2023;30:250-256.
Critical care patients may be vulnerable to medication errors due to the complex nature of the intensive care unit (ICU). This systematic review of 47 studies found that as many as 80% of patients on critical care services experienced medication-related problems after discharge from the hospital. Common problems include inappropriate continuation of newly-prescribed medications as well as discontinuation of chronic disease medications.
Westbrook JI, Li L, Raban MZ, et al. NPJ Digit Med. 2022;5:179.
Pediatric patients are particularly vulnerable to medication errors. This cluster randomized controlled trial examined the short- and long-term impacts of an electronic medication management (eMM) system implemented at one pediatric referral hospital in Australia. Findings suggest that eMM implementation did not reduce medication errors in the first 70 days of use, but researchers observed a decrease in medication errors one year after implementation, suggesting long-term benefits.
Keil O, Brunsmann K, Boethig D, et al. Paediatr Anaesth. 2022;32:1144-1150.
Harm from pediatric anesthesia-related errors is infrequent, but largely preventable. This pediatric hospital developed and implemented an anesthesia-specific checklist to be used before anesthesia induction. This study presents the types of errors identified by the checklist over the course of one year.
Prabhu V, Mikhly M, Chung R, et al. Am J Med Qual. 2022;37:72-80.
… Am J Med Qual … Encouraging adverse event reporting among … to improving patient safety. This hospital implemented a multi-pronged intervention – using a combination of … and long-term. … Prabhu V, Mikhly M, Chung R, et al. I-PSI: short- and long-term efficacy of a comprehensive …
Li Q, Hu P, Kang H, et al. J Nutr Health Aging. 2020;25:492-500.
Missed and delayed diagnosis are a known cause of preventable adverse events. In this cohort of 107 patients with severe or critical COVID-19 in Wuhan, China, 45% developed acute kidney injury (AKI). However, nearly half of those patients (46%) were not diagnosed during their stay in the hospital. Patients with undiagnosed AKI experienced greater hospital mortality than those without AKI or diagnosed AKI. Involvement of intensive care kidney specialists is recommended to increase diagnostic awareness.
WebM&M Case February 1, 2019
Following surgery under general anesthesia, a boy was extubated and brought to postanesthesia care unit (PACU). Due to the patient's age and length of the surgery, the PACU anesthesiologist ordered continuous pulse-oximetry monitoring for 24 hours. Deemed stable to leave the PACU, the boy was transported to the regular floor. When the nurse went to place the patient on pulse oximetry, she realized he was markedly hypoxic. She administered oxygen by face mask, but he became bradycardic and hypotensive and a code blue was called.
Short K, Chung YJ. Nursing (Brux). 2019;49:52-57.
Alarm fatigue contributes to distraction and can diminish care safety. This commentary reviews a single-center project that used smartphone technology to enhance cardiac monitoring. The authors describe the structure of the project, use of Plan-Do-Study-Act cycles to design the application, results of the pilot, and plans to expand the use of this technology to other units and broaden monitoring targets. A WebM&M commentary discussed harm associated with alarm fatigue.
Short-Life Working Group on Hospital Reports. Edinburgh, Scotland: Royal College of Surgeons of Edinburgh; July 31, 2017.
… deficiencies in surgical training that can contribute to a stressful work environment and diminish the safety of care … and reduce the potential for error, including establishing a strong team culture and promoting human factors training. … Short-Life Working Group on Hospital Reports. Edinburgh, …
Bergman AA, Flanagan ME, Ebright PR, et al. BMJ Qual Saf. 2016;25:84-91.
This qualitative analysis found that anticipatory management conversation occurred in most physician-to-physician and nurse-to-nurse verbal handoffs. The authors suggest that structured handoffs should be supplemented with additional verbal communication regarding relevant contextual information.

Philibert I, Barach P, eds. BMJ Qual Saf. 2012;21(suppl 1):i1-i128.

… Articles in this supplement highlight findings of a multi-national effort to improve transitions from the … including research , interventions, and tools. … Philibert I, Barach P, eds. BMJ Qual Saf. 2012;21(suppl 1):i1-i128. … … Wollersheim … Gademan … Ohlén … Hansagi … Farnan … Arora … J. … J. … C. … JQ Young … ES Patterson … M. Wohlauer … RM …
Merry A, Webster CS, Hannam J, et al. BMJ. 2011;343:d5543.
Drug administration errors are a major safety concern in anesthesiology, as even routine cases can require administration of several high-risk medications. In this randomized controlled trial, a novel system for drug administration was evaluated in comparison with usual anesthesia practice. The new system was designed according to human factors engineering principles and included proven safety measures such as barcode medication administration. Although fewer overall errors occurred with the new system, the reduction in administration errors occurred only when barcoding was performed consistently and safety alerts were heeded. The anesthesia field has long been a leader in patient safety, and in fact, some of the earliest studies in the patient safety field evaluated the role of human factors in anesthesia medication administration errors.
Mayer CM, Cluff L, Lin W-T, et al. Jt Comm J Qual Patient Saf. 2011;37:365-374.
… Jt Comm J Qual Patient Saf … Jt Comm J Qual Patient Saf … Teamwork … to yield improved patient outcomes, in part because of a lack of evidence showing that teamwork training results in … and also improved 2 of 3 targeted patient-level outcomes. A related editorial discusses the role of targeted teamwork …

Batalden P, Davidoff F, eds. BMJ Qual Saf. 2011;20(suppl 1):1-105.  

… BMJ Qual Saf. 2011;20(suppl 1):1-105.   … P. … F. … M. … J. … C. … S. … LP … J. … L. … GJ … R. … M. … PM … GS … C. … D. … JM … J. … AP … R. … B. … P. … A. … JL … D. … GR … RJ … M. … Batalden … Davidoff … Marshall … Vincent … Goldmann … Bartunek … Lynn … Owens … Amalberti … Bergman … Glasziou … Langley … Denis … Neuhauser … Baker … …

Huang YH, Chen PY, Grosch JW, eds. Accid Anal Prev. 2010;42:1421-1522.   

…    … Walker CT Jr. … JM … ME … SC … KP … PY … J. … GJ … A. … YH … JW … L. … G. … Y. … F. … LM … VJ … M. … … … AK … ML … JL … E. … TM … AX … RR … JE … LE … D. … Beus … Bergman … Payne … Cigularov … Chen … Rosecrance … Fogarty … …