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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 - 9 of 9 Results
Berdot S, Vilfaillot A, Bézie Y, et al. BMC Nurs. 2021;20:153.
Interruptions have been identified as a common source of medication errors. In this study of the effectiveness of a “do not interrupt” vest worn by nurses from medication preparation to administration, neither medication administration error or interruption rates improved.
Daupin J, Perrin G, Lhermitte-Pastor C, et al. J Oncol Pract. 2019;25:1195-1203.
Prior research has shown that oncology pharmacists can improve the safety of chemotherapy administration. In this prospective study, researchers found that 129 of 1346 chemotherapy prescriptions issued in a 1-month period at a single university hospital required intervention by an oncology pharmacist. The majority of such interventions were perceived as having a significant impact on patient safety.
Faisy C, Davagnar C, Ladiray D, et al. Int J Nurs Stud. 2016;62:60-70.
Higher patient-to-nurse staffing ratios have been linked to worse patient outcomes. In this 8-year observational cohort study in a single intensive care unit, increased patient-to-nurse staffing ratios and arrival of inexperienced resident physicians were associated with higher rates of adverse events including unexpected cardiac arrest, unanticipated extubation, and readmission.
François P, Prate F, Vidal-Trecan G, et al. BMC Health Serv Res. 2016;16:35.
Morbidity and mortality (M&M) conferences are a classic patient safety education and feedback strategy. This study found that elements of M&M conferences, including thorough investigation of failures, predicted whether an improvement initiative was implemented. This work suggests that M&M conferences can be optimally designed to foster subsequent improvement efforts.
Berdot S, Roudot M, Schramm C, et al. Int J Nurs Stud. 2016;53:342-350.
This meta-analysis examined the efficacy of interventions to improve the safety of medication administration. Researchers looked at studies that used training methods (e.g., simulation) and technology approaches (e.g., computerized physician order entry and automated medication dispensing systems). The authors conclude that more randomized or experimental trials are needed in order to characterize the effect of these interventions, although they acknowledge the increasing implementation of barcode medication administration as a safety strategy.
Berdot S, Gillaizeau F, Caruba T, et al. PLoS One. 2013;8:e68856.
Medication administration errors are known to be common, but determining a true incidence has been difficult due to varying error definitions across studies. This systematic review, which used a standardized definition of administration errors, found that approximately 1 in 10 medication doses in hospitalized patients was administered incorrectly.