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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 23 Results
Aiken LH, Lasater KB, Sloane DM, et al. JAMA Health Forum. 2023;4:e231809.
While the association between clinician burnout and patient safety are not new, the COVID-19 pandemic brought this safety concern back to the forefront. In this study conducted at 60 US Magnet hospitals, nurses and physicians reported high levels of burnout and rated their hospital unfavorably on patient safety. Increased nurse staffing was the top recommendation to reduce burnout with less emphasis on wellness and resilience programs.
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.
Braun B, Chitavi SO, Perkins KM, et al. Jt Comm J Qual Patient Saf. 2020;46:531-541.
In this retrospective review of ambulatory care infection prevention and control (IPC) breaches reported to state health departments, the authors observed 5% rate of breaches and found that common breaches involved sterilization and disinfection of reusable devices, device reprocessing, and IPC infrastructure. These and other breaches highlight opportunities for additional training, leadership oversight, and resource investment.
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, 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.
Fridkin SK, Baggs J, Fagan R, et al. MMWR Morb Mortal Wkly Rep. 2014;63:194-200.
Antibiotics are among the most remarkable life-saving advances of modern medicine. However, when used incorrectly these medications pose serious risks for patients due to adverse effects and the potential to cause complicated infections, including those resistant to multiple antibiotics. This national database study found that more than half of all patients discharged from a hospital in 2010 received antibiotics during their stay. Many of these antibiotics were deemed to be unnecessary, and there was wide variation seen in antibiotic usage across hospital wards. A model accounting for both direct and indirect effects of antibiotics predicted that decreasing hospitalized patients' exposure to broad-spectrum antibiotics by 30% would lead to a 26% reduction in Clostridium difficile infection. The CDC recommends that all hospitals implement antibiotic stewardship programs, and this article provides core elements to guide these efforts. An AHRQ WebM&M commentary describes inappropriate antibiotic usage that resulted in a patient death. Dr. Alison Holmes spoke about infection prevention and antimicrobial stewardship in a recent AHRQ WebM&M interview.
Guh AY, Thompson ND, Schaefer MK, et al. Med Care. 2012;50:785-91.
This review documents 35 cases of unsafe injection practices in the United States over the past decade, leading to more than 100,000 patients being exposed to communicable diseases. In most cases, clinicians reused syringes or medication vials intended for single-dose usage. Although the authors ascribe these violations to failure to follow basic infection control practices, subsequent analysis of one widely publicized case also revealed that safety culture played a role, as nurses did not feel empowered to report improper injection practices due to fear of retaliation. The article also discusses the challenges of notifying patients about potential harm, and a recent Australian article describes the notification process used after a similar large-scale safety problem was identified.
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.
Schaefer MK, Jhung M, Dahl M, et al. JAMA. 2010;303:2273-9.
This study discovered that nearly 70% of ambulatory surgical centers had at least one lapse in infection control. The most common lapses involved using a single-dose medication vial for more than one patient and failure to adhere to recommended practices for equipment handling.
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.