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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 22 Results
Weiner-Lastinger LM, Pattabiraman V, Konnor RY, et al. Infect Control Hosp Epidemiol. 2022;43:12-25.
Using data reported to the National Healthcare Safety Network, this study identified significant increases in the incidence of healthcare-associated infections from 2019 to 2020. The authors conclude that these findings suggest a need to return to conventional infection control and prevention practices and prepare for future pandemics.
Geller AI, Conrad AO, Weidle NJ, et al. Pharmacoepidemiol Drug Saf. 2021;30:573-581.
The Institute for Safe Medication Practices (ISMP) classifies insulin as a high-risk medication. This study examines insulin mix-up errors that resulted in emergency department visits or other serious adverse events. Most cases of medication mix-up involved rapid-acting insulin. Recommended prevention strategies include increased patient education and human factors engineering.
Agarwal M, Lovegrove MC, Geller RJ, et al. J Pediatr. 2020;219.
Parents are advised to keep medications inaccessible to young children to avoid accidental ingestions. This study prospectively enrolled nearly 4,500 individuals calling poison control centers about unsupervised solid dose medication exposure in young children (ages 5 years and younger) to identify the types of containers from which young children accessed these medications. The majority of incidents (71.6%) involved children 2 years and younger. Incidents were equally divided among calls involving prescription-only medications, over-the-counter (OTC) projects requiring child-resistant packaging, and OTC projects not requiring such packaging. One-third of all incidents involved medication that had been removed from the original container; this was more likely in incidents involving prescription drugs compared to OTC drugs (adjusted odds ratio, 3.39; 95% CI, 2.87-4.00).  These findings suggest that unsupervised medication exposures in young children are just as often the result of adults removing medications from original packaging as the result of improper use or failure of child-resistant packaging.
Magill SS, O'Leary E, Janelle SJ, et al. N Engl J Med. 2018;379:1732-1744.
Health care–associated infections (HAIs) are a key cause of preventable harm in hospitals. Successful programs to avert HAIs include the comprehensive unit-based safety program to reduce catheter-related bloodstream infections and the AHRQ Safety Program for Surgery to prevent surgical site infections. This survey of 12,299 patients at 199 hospitals on a single day enabled researchers to estimate the prevalence of HAIs in the United States. In 2015, 3.2% of hospitalized patients experienced an HAI, a 16% decrease compared to a similarly derived estimate in 2011. The most common HAIs were pneumonia and Clostridium difficile infections, while the biggest reductions were in urinary tract and surgical site infections. This data emphasizes the importance of identifying strategies to combat pneumonia in nonventilated patients, which remains common and less well-studied than other HAIs. A past PSNet perspective discussed the history around efforts to address preventable HAIs, including federal initiatives.
Shehab N, Lovegrove MC, Geller AI, et al. JAMA. 2016;316:2115-2125.
Adverse drug events (ADEs) in outpatient settings can cause significant morbidity and mortality. Updating a prior study, this surveillance study identified more than 40,000 ADEs among 58 emergency departments in the United States. Investigators estimated that 4 emergency department visits for ADEs occurred per 1000 patients annually during the study period, with more than one-quarter of these visits resulting in hospitalization. Antibiotic reactions were the most common ADE for children. Among patients age 65 or older, anticoagulants, diabetes medications, and opioids were most commonly implicated in ADEs, as seen in a previous study. Medications considered inappropriate for older adults according to Beers criteria were involved in less than 2% of ADEs. The authors conclude that preventing ADEs requires attention to older adults and to antibiotic, anticoagulant, diabetes, and opioid medications, consistent with recommendations from the 2014 National Action Plan for Adverse Drug Event Prevention.
Geller AI, Shehab N, Weidle NJ, et al. N Engl J Med. 2015;373:1531-40.
Dietary supplements can cause harm, especially in combination with prescribed medication, and their use is increasing. This report from an established surveillance system sampled emergency department visits related to dietary supplements. The results suggest that adverse events related to dietary supplements cause 23,000 emergency department visits per year in the United States. Ingestions by unsupervised children accounted for nearly a quarter of the visits. Other common events included palpitations, chest pain, or tachycardia related to weight loss or energy supplements. The authors note that there is no legal requirement for supplement manufacturers to identify potential adverse effects on the products themselves, and they encourage clinicians to educate patients about potential adverse reactions.
Lovegrove MC, Mathew J, Hampp C, et al. Pediatrics. 2014;134:e1009-16.
Accidental ingestions of prescription medications by children pose serious safety risks. Prior efforts to mitigate this hazard include child-resistant packaging and public education about safe storage. This study used large databases to estimate that approximately 10,000 children under age 6 are emergently hospitalized following an accidental ingestion annually in the United States. Three-quarters of these events involved 1- or 2-year-old children. Opioids and benzodiazepines were the most common culprits, and 12 active ingredients accounted for nearly half of the hospitalizations. These findings suggest that strategies to specifically target a select group of high-risk medications could have a substantial impact on serious adverse drug events related to accidental ingestions.
Magill SS, Edwards JR, Bamberg W, et al. N Engl J Med. 2014;370:1198-208.
Health care–associated infections (HAIs) are a serious and common cause of patient harm. The Centers for Disease Control and Prevention (CDC) created the National Healthcare Safety Network to provide information on incidence rates of infections, but most hospitals limit reporting to only certain complications. This multistate prevalence study found that approximately 4% of sampled patients had HAIs. Using a model to extrapolate these findings, nearly 650,000 patients in United States hospitals are estimated to have had an HAI in 2011. Infections associated with devices—including central lines, urinary catheters, and ventilators—have been a major focus of strategies to decrease HAIs, but together they accounted for only about a quarter of all HAIs. Clostridium difficile was responsible for more than 12% of infections, highlighting the importance of efforts to mitigate this life-threatening disease. A recent CDC report suggested the potential promise of antibiotic stewardship programs to decrease C. difficile rates.
Geller AI, Shehab N, Lovegrove MC, et al. JAMA Intern Med. 2014;174:678-686.
According to this large study, nearly 100,000 emergency department visits and 30,000 hospitalizations in the United States each year are due to insulin-related hypoglycemia and errors. Patients older than 80 years were found to be at highest risk for these adverse events.
Budnitz DS, Lovegrove MC, Shehab N, et al. New Engl J Med. 2011;365:2002-2012.
Partnership for Patients set an ambitious goal to reduce preventable readmissions by 20% in 2013. Adverse drug events contribute significantly to undesired outcomes and provide an ongoing area for prevention strategies. This study used a national surveillance database and examined nearly 100,000 emergency hospitalizations attributed to adverse drug events in elderly patients between 2007 and 2009. Investigators found that nearly half the hospitalizations were in adults older than 80 years and two-thirds were due to unintentional overdoses. The most common medications implicated were warfarin, insulin, oral antiplatelet agents, and oral hypoglycemic agents. The authors suggest that targeted strategies to minimize risk associated with these high-risk medications may reduce preventable hospitalizations in older adults.
Shehab N, Schaefer MK, Kegler SR, et al. Pediatrics. 2010;126:1100-7.
This study found substantially reduced emergency department visits for over-the-counter (OTC) cough and cold medication–related adverse events. The authors advocate for greater efforts to improve packaging information and education around avoiding use of these high-risk OTC medications in infants.
Schillie SF, Shehab N, Thomas KE, et al. Am J Prev Med. 2009;37:181-7.
This study sought to characterize the frequency and causes of adverse drug events leading to emergency department visits in children. In contrast to adults, the majority of medication overdoses in children were due to unsupervised, accidental ingestions, while medication errors accounted for less than 15% of cases. Errors involving over-the-counter medications were more common than prescription medications, and the most common error was administering the wrong dose. Low health literacy is tied to misunderstanding prescription drug instructions, and a prior study successfully used pictogram-based education to reduce dosing errors in children. The study likely underestimates the true incidence of adverse drug events in children, as most cases are managed by poison control centers without requiring visits to a physician.