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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 - 6 of 6 Results
Morriss FH, Abramowitz PW, Nelson S, et al. Am J Health Syst Pharm. 2011;68:57-62.
This study observed that neonates receiving opioids in the intensive care setting were at increased risk of a preventable adverse drug event. Implementation of a bar-code–assisted medication administration system reduced the risk of harm from opioid medication errors.
Picone DM, Titler MG, Dochterman J, et al. Am J Med Qual. 2008;23:115-127.
The vast majority of medication errors among geriatric patients at a university hospital were preventable. Factors predicting medication errors included patient factors, medication factors (i.e., polypharmacy), and systems factors (i.e., nurse staffing changes).
Weissman JS, Rothschild JM, Bendavid E, et al. Med Care. 2007;45:448-55.
Past research suggests a relationship between nursing workload and quality of care in hospitalized patients. This study examined the relationship between hospital workload and adverse events and discovered that a hospital operating consistently near capacity had increased rates of adverse events. Investigators reviewed more than 6800 patient charts at four different teaching hospitals and found workload effects at only one of the sites. At this site, they estimated that a 10% increase in occupancy led to a 15% increase in adverse events. The authors suggest that consistently high workloads, where patient to nurse ratios may increase, pose a risk to patient safety.
Rothschild JM, Keohane C, Cook F, et al. Crit Care Med. 2005;33:533-540.
This prospective, randomized time series trial examined the impact of smart pumps with integrated decision support on adverse medication events. Investigators used a decision support system that allowed categorization of noted events by type, preventability, and severity. Despite finding similar serious medication error rates in both study groups, opportunities for intervention were discovered through improved detection with the new technology. The authors concluded that improved infusion safety can result from incorporating novel technology but stressed that behavioral and educational factors of users must be considered.