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.
DeCoster MM, Spiller HA, Badeti J, et al. Pediatrics. 2023;Epub Sep 18.
Data from the National Poison Data System is useful for describing characteristics and trends of out-of-hospital medication errors. This retrospective study describes trends in therapeutic errors involving attention deficit/hyperactivity disorder (ADHD) medications as reported to poison control centers in the United States. From 2000 to 2021, errors increased by 300%, with more than half classified as "inadvertently took or was given medication twice." Although no deaths were reported and less than 5% resulted in moderate or major medical outcomes, increased patient and caregiver education and child-resistant medication containers are needed.
Abdallah W, Johnson C, Nitzl C, et al. J Health Organ Manag. 2019;33:695-713.
Organizations are encouraged to learn from failure. The authors surveyed hospital pharmacists to explore how organizational learnings relates to safety culture and found that the strongest contributors to safety culture were organizations prioritizing and supporting training and education.
Griffiths P, Maruotti A, Saucedo AR, et al. BMJ Qual Saf. 2019;28:609-617.
… BMJ Qual Saf … BMJ Qual Saf … There is a clear link between nurse staffing ratios and patient … nursing to ensure safe acute care. … Griffiths P, Maruotti A, Recio Saucedo A, et al. Nurse staffing, nursing assistants and hospital …
Griffiths P, Ball JE, Bloor K, et al. Southampton, UK: NIHR Journals Library; 2018.
… 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 … direct relationship between safety and staffing levels . A PSNet perspective examined the relationship between missed …
Kamboj A, Spiller HA, Casavant MJ, et al. Pharmacoepidemiol Drug Saf. 2018;27:902-911.
… … Pharmacoepidemiol Drug Saf … Medication errors remain a major source of preventable patient harm . Using data from … that the rate of such errors increased over time. … Kamboj A, Spiller HA, Casavant MJ, Chounthirath T, Hodges NL, Smith GA. Antidepressant and antipsychotic medication errors …
Louch G, Mohammed MA, Hughes L, et al. Health Expect. 2019;22:102-113.
The Patient Reporting and Action for a Safe Environment (PRASE) study was a large patient engagement intervention that proactively solicited hospitalized patient feedback about their safety. This qualitative study found that hospital volunteers could use PRASE tools to sustainably solicit patient feedback in place of paid study staff. However, health care workers did not consistently have means to act upon the safety hazards that patients and volunteers identified. A recent PSNet interview with Rebecca Lawton, lead investigator on the PRASE study, discussed her experience and insights in patient engagement research.
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.
King SA, Casavant MJ, Spiller HA, et al. Pediatrics. 2018;141.
The prevalence of attention-deficit/hyperactivity disorder (ADHD) among children in the United States has risen significantly over the past two decades, accompanied by an increase in patients receiving medications (usually stimulants such as methylphenidate) for treatment. This retrospective cohort study found that this surge in diagnoses of ADHD has also been accompanied by an uptick in medication toxicity, as measured by calls to poison control centers. This increase was most prominent between 2000 and 2011, but the rate declined slightly between 2011 and 2014. Most of the calls were classified as unintentional and occurred in patients who had been prescribed a medication for ADHD. However, among adolescents, half of the exposures involved an intentional medication overdose. Although medications for ADHD are generally considered safe—and the vast majority of patients in this study did not require care for their exposure—this study provides an important estimate of the risks associated with these medications and the types of patients who may be most vulnerable.
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.
Louch G, O'Hara JK, Mohammed MA. Health Expect. 2017;20:1143-1153.
… … Health Expect … This qualitative evaluation found that a volunteer-administered patient engagement intervention was … staff. The authors suggest that this intervention is a promising approach to enhance patient engagement . …
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 …
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.
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 …