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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 69 Results
Liang C, Miao Q, Kang H, et al. Stud Health Technol Inform. 2019;264:983-987.
This AHRQ-funded analysis of patient safety research found that research output—as measured by federal grant funding and peer-reviewed publications—increased sharply between 1995 and 2014. Publication of the To Err Is Human report and passage of federal budget stimulus funds were associated with an increase in patient safety publications and research funding.
Guenter P, Worthington P, Ayers P, et al. Nutr Clin Pract. 2018;33:295-304.
Administration of parental nutrition is a specialized process that requires distinct competencies to be safe. This guideline recommends standardized competencies for clinicians to develop and maintain to ensure safe and reliable administration of parenteral nutrition therapy in various care environments and team configurations.
Holcombe B, Mattox TW, Plogsted S. Nutr Clin Pract. 2018;33:53-61.
Shortages of medications and compounding components can lead to diversion from recommended treatment. This review describes problems that can arise due to shortages in parenteral nutrition components. The authors recommend strategies to reduce risks associated with lack of ingredients for parenteral nutrition.
Boullata JI, Carrera AL, Harvey L, et al. JPEN J Parenter Enteral Nutr. 2017;41:15-103.
Enteral nutrition is provided to patients in a variety of care settings, and errors in the enteral nutrition–use process may lead to safety hazards. Drawing from current evidence, these consensus guidelines recommend best practices to ensure safety of enteral nutrition, including a six-step standardized approach to administering eternal nutrition that involves independent double-checks and automation with forcing functions.
Antiel RM, Blinman TA, Rentea RM, et al. Pediatrics. 2016;137:e20153828.
Physicians have become more comfortable with recognizing and disclosing errors to patients in the past few decades, but speaking up about a peer's error remains challenging. Discussing a case involving a surgeon discovering a serious mistake made by a colleague, this commentary provides insights from surgical and bioethics experts on how to address the situation.
Guenter P, Jensen G, Patel V, et al. Jt Comm J Qual Patient Saf. 2015;41:469-473.
Previous studies have explored safety issues related to parenteral nutrition processes, but problems associated with general nutrition for inpatients have received scant attention. This commentary advocates for promoting awareness around malnutrition as a hospital-acquired condition and outlines 12 actions to improve the safety of nutrition care for hospitalized patients, including use of routine assessments and checklists.
Guenter P, Boullata JI, Ayers P, et al. Nutr Clin Pract. 2015;30:570-6.
Parenteral nutrition has the potential to result in patient harm if administered or prepared incorrectly. This commentary builds on a set of overarching recommendations to define competencies that enable the safe prescribing and delivery of parenteral nutrition. The model is designed to help organizations apply the suggestions in their particular care environments.
Guenter P. Nutrition in Clinical Practice. 2014;29.
Redesigning tubing connectors according to new ISO standards has the potential to reduce tubing misconnections. This commentary provides information about changes to enteral connectors to prepare clinicians to use the new devices in their organizations.
Ayers P, Adams S, Boullata JI, et al. Nutr Clin Pract. 2014;29:277-82.
This commentary describes strategies to promote the use of parenteral nutrition safety guidelines in practice. The authors include examples of how checklists can improve adoption of best practices and discuss the potential for instituting policies and providing information about drug shortages to drive integration of the recommendations into daily work.
Ayers P, Adams S, Boullata JI, et al. JPEN J Parenter Enteral Nutr. 2014;38:296-333.
… JPEN J Parenter Enteral Nutr … JPEN J Parenter Enteral Nutr … This … associated with parenteral nutrition . … Ayers P, Adams S, Boullata J, et al. A.S.P.E.N. parenteral nutrition safety consensus recommendations.  …

Andris DA, Mirtallo JM, Guenter P, eds. JPEN J Parenter Enteral Nutr. 2012;36(2 Suppl):1S-62S.  

… nutrition ordering , formulation, and delivery. … Andris DA, Mirtallo JM, Guenter P, eds. JPEN J Parenter Enteral Nutr. 2012;36(2 Suppl):1S-62S.   … DAJIATMRMHSMJ. … KFE. … JDB. … ESJM … …
Simmons D, Symes L, Guenter P, et al. Nutr Clin Pract. 2011;26:286-293.
Analyzing published case studies on tubing misconnections and expert recommendations for improvement, this review suggests that equipment redesign—making enteral and IV systems incompatible—is the most effective strategy to reduce incidence of such errors.

Simmons D, ed. Crit Care Nurs Clin North Am. 2010;22:161-290. 

Articles in this special issue discuss safe practices, effective staffing, teamwork, and event analysis to enhance patient safety in the critical care setting.

Cohen MR, Smetzer JL. Hosp Pharm. 2010:45(5);352-355.   

This monthly selection of error reports discusses incidents involving look-alike drug names, concentration dosage error, and harm related to abbreviation use.

J Patient Saf. 2010;6(1):1-47, 52-56.  

… Forum (NQF) Safe Practices for Better Healthcare .     … J Patient Saf . 2010;6(1):1-47, 52-56.   … D. … J. … CR … D. … … A. … J. … L. … S. … S. … D. … DW … WW … LH … PB … C. … MRJ. … ME … D. … B. … P. … A. … S. … Quaid … Thao … Denham … … Classen … Bates … George … Burgess … Angood … Keohane … Cohen … Dingman … Foley … Ford … Martins … O'Regan … …
Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:1062-1065.
This monthly column reports on an error involving products with similar names (quinine and quinidine) and discusses the Anesthesia Patient Safety Foundation's recommendations for safe use of patient-controlled analgesia.