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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 - 15 of 15 Results
Grissinger M. P T. 2018;43:645-666.
Although best practices that support safe and reliable medication therapy exist, they are not uniformly embedded in care delivery. This three-part series discusses medication safety risks and highlights topics such as wrong-patient orders, inadequate patient understanding of drug instructions, and poor lighting.
Patterson ES, Sillars DM, Staggers N, et al. Jt Comm J Qual Patient Saf. 2017;43:375-385.
Electronic medical records offer users the ability to copy information forward from note to note. This practice is nearly universal, despite the attendant safety risks that may result if incorrect or outdated information is propagated in this fashion. Although most attention has focused on copying and pasting by physicians, nurses may use this function as well. This AHRQ-funded study used a multiple stakeholder approach to develop consensus recommendations for nurses' copy-forward practices, seeking to establish a balance between patient safety and nurses' work efficiency. Investigators recommend that copying and pasting should be allowed, but that copied text should be easily identifiable within the electronic medical record, staff should receive formal training on the appropriate and safe use of copy-forward, and the practice should be monitored and assessed by supervisors. Efforts to limit copying and pasting will likely continue to be hindered by the fact that most clinicians do not perceive that copy-forward practices pose patient safety risks, despite examples to the contrary.
WebM&M Case September 1, 2011
Following surgery, a cancer patient was receiving total parenteral nutrition and lipids through a central venous catheter and pain control through an epidural catheter. A nurse mistakenly connected a new bottle of lipids to the epidural tubing rather than the central line, and the error was not noticed for several hours.
Guenter P, Hicks RW, Simmons D. Nutr Clin Pract. 2009;24:325-34.
This review surveys information on enteral nutrition administration and tubing misconnections and recommends employing increased standards and forcing functions to reduce their incidence.
WebM&M Case March 1, 2008
… orders led to patient harm. In one case reported to the USP-ISMP medication error reporting program (MERP), an … specific instructions on when to resume the medication. … Matthew Grissinger, RPh … Director, Error Reporting Programs …
Hicks RW, Becker SC, Cousins DD. J Pediatr Nurs. 2006;21:290-8.
This study examined data from a voluntary medication error reporting system (Medmarx) to determine the incidence of harmful pediatric medication errors, the classes of medications frequently associated with error, and the types of errors that occurred. Harmful errors were defined as errors that resulted in temporary or permanent harm to the patient or required immediate intervention to avoid harm. Opioid analgesics, antimicrobials, and antidiabetic agents were most commonly associated with harmful medication errors, collectively accounting for 23.5% of the errors reported. The major type of error was administration at an incorrect dose or quantity (especially for opioid analgesics), followed by omission errors. These findings are similar to those of a previous study. The authors review the systems factors contributing to common medication errors and suggest strategies for error prevention.