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.
Griffiths P, Maruotti A, Saucedo AR, et al. BMJ Qual Saf. 2019;28:609-617.
There is a clear link between nurse staffing ratios and patient safety. This study corroborates the finding that lower registered nurse staffing and higher numbers of patients admitted per nurse are associated with increased rates of in-hospital mortality. The results underscore the importance of adequate nursing to ensure safe acute care.
Griffiths P, Ball JE, Bloor K, et al. Southampton, UK: NIHR Journals Library; 2018.
Missed nursing care has been linked to safety problems, but ensuring reliable levels of nurse staffing remains challenging. This report provides the results of a 3-year investigation into whether tracking of vital signs by nursing staff could serve as a viable measure for safe patient coverage. The report identified correlations between low staffing, missed vital sign observation, length of stay, and likelihood of mortality. However, record review found no direct relationship between safety and staffing levels. A PSNet perspective examined the relationship between missed nursing care and patient safety.
Kamboj A, Spiller HA, Casavant MJ, et al. Pharmacoepidemiol Drug Saf. 2018;27:902-911.
Medication errors remain a major source of preventable patient harm. Using data from the National Poison Data System from 2000 to 2012, researchers found that medication errors associated with the use of antidepressant or antipsychotic medications outside of health facilities occurred frequently and that the rate of such errors increased over time.
Griffiths P, Recio-Saucedo A, Dall'Ora C, et al. J Adv Nurs. 2018;74:1474-1487.
Inadequate hospital nurse staffing is linked to increased mortality. This systematic review found that lower nurse staffing is associated with more reports of missed nursing care. Two of the authors summarized the science of missed nursing care in a recent PSNet perspective.
Kamboj AK, Spiller HA, Casavant MJ, et al. Ann Pharmacother. 2017;51:825-833.
Medication errors are common in outpatient settings. This retrospective review of data from the National Poison Data System reveals that rates of medication errors involving cardiovascular drugs are rising. Consistent with prior studies of outpatient adverse drug events, older individuals had the highest rate of medication errors. These results underscore the ongoing challenge of achieving safe outpatient medication use.
Hodges NL, Spiller HA, Casavant MJ, et al. Clin Toxicol (Phila). 2018;56:43-50.
… data from the National Poison Database System. Over a 13-year study period, 67,603 unintentional medication … errors included dosing and administration errors. A previous WebM&M commentary described a near miss in which a patient almost administered the wrong …
Robinson EJ, Smith GB, Power GS, et al. BMJ Qual Saf. 2016;25:832-841.
Patients admitted on the weekend may be at increased risk for complications and mortality. This analysis of a large national database examined variations in outcomes following in-hospital cardiac arrest by day versus night and weekday versus weekend. The investigators found that return of spontaneous circulation for 20 minutes or longer, a positive outcome, was more likely during weekday business hours compared with nights or weekends. Similarly, survival to hospital discharge was worse on nights and weekends. These results are consistent with prior studies that demonstrated worse outcomes for patients admitted to hospitals during nights or weekends. Raising concerns that patients who had in-hospital cardiac arrest on nights or weekends might have been more ill at baseline, a related editorial encourages rigorous evaluation of any staffing changes meant to address the weekend effect.
Smith MD, Spiller HA, Casavant MJ, et al. Pediatrics. 2014;134:867-76.
Medication errors are prevalent among children, especially those younger than 6 years old. Analyzing a database of telephone calls to poison control centers in the United States, this study found that medication errors are frequent. Adverse drug events are most likely with liquid medications and often occur because of confusion with units of measure or administration of an incorrect medication. These findings support prior studies which revealed the challenges related to liquid medication dosing. Of concern, compared with older children, infants (children under age 1) were twice as likely to die or require admission to the intensive care unit for medication errors. American Academy of Pediatrics guidelines on standardized units of measure may address some of these administration errors. A previous AHRQ WebM&M commentary discusses medication safety in pediatric medicine.
Schmidt PE, Meredith P, Prytherch DR, et al. BMJ Qual Saf. 2015;24:10-20.
… to requiring more aggressive interventions and transfer to a higher level of care. Rapid response teams have been widely … utilized an electronic physiological surveillance system—a real-time decision support system based on patients' vital … physiological surveillance system was associated with a statistically significant reduction in mortality for a …
Spiller HA, Borys DJ, Ryan ML, et al. Ann Pharmacother. 2011;45:17-22.
Preventing medication errors remains a focus of safety interventions, particularly for high-risk medications such as insulin. While insulin-related adverse events are well described in hospital and nursing home settings, the scope of the problem in ambulatory care is less understood. This study analyzed nearly 4000 insulin exposures reported to poison centers over the past decade and found a mean annual increase of 18% over that time period. Unintentional therapeutic errors accounted for 68% of the total with a progression from 41% to 78% over the study period. Factors associated with these errors included adults older than 40 years and administration in the late evening hours. These findings raise opportunities for improvement in insulin safety outside the heavily studied inpatient setting. A past AHRQ WebM&M commentary discussed the challenges in managing insulin therapy in the hospital setting.