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.
Christensen SM, Andrews SR, Fox ER. Am J Health Syst Pharm. 2023;80 :S119-S122.
To maximize safety benefits of smart infusion pumps, drug libraries between the pump, electronic health record (EHR) and pharmacy must be standardized. This article describes the proactive standardization between drug libraries for continuous infusions, including medication names, concentrations, and pump rates. 82 updates were required across the three libraries.
Stewardship interventions seek to optimize use of healthcare services, such as diagnostic tests or antibiotics. This article reports findings from a 14-site multidisciplinary collaborative evaluating pediatric intensive care unit (PICU) blood culture practices before and after implementation of a diagnostic stewardship intervention. Researchers found that rates of blood cultures, broad-spectrum antibiotic use, and central line-associated blood stream infections (CLABSI) were reduced postintervention.
Lin MP, Vargas-Torres C, Shin-Kim J, et al. Am J Emerg Med. 2022;53:135-139.
Drug shortages can result in patient harm, such as dosing errors from a medication substitution. In this study, 28 of the 30 most frequently used medications in the emergency department experienced shortages between 2006 and 2019. The most common reasons for shortages were manufacturing delays and increased demand. The COVID-19 pandemic exacerbated pre-existing drug shortages.
Banerjee R, Thurm CW, Fox ER, et al. Pediatrics. 2018;142.
Drug shortages can disrupt care processes and diminish medication safety. This commentary highlights distinct concerns associated with disruptions in access to appropriate antibiotics for pediatric patients and the lack of evidence exploring this common problem. The authors suggest strategies to address these shortages, including antibiotic stewardship and government oversight. A WebM&M commentary discussed challenges associated with medication shortages.
Fox ER, McLaughlin MM. Am J Health Syst Pharm. 2018;75:1742-1750.
Drug shortages are a persistent threat to safe patient care. These guidelines provide a structured approach for care teams to develop an action plan to reduce risks when faced with drug shortages in their work. Recommendations include conducting operational assessments, establishing a drug shortage team, and communicating with patients and providers when a shortage occurs.
Fleming-Dutra KE, Hersh AL, Shapiro DJ, et al. JAMA. 2016;315:1864-1873.
More than 12% of all outpatient visits in the United States in 2010–2011 resulted in an antibiotic prescription, of which approximately 30% were inappropriate, according to this population-based analysis. Inappropriate antibiotic prescribing increases the risk of antibiotic-resistant infections and is a recognized patient safety risk. A WebM&M commentary discusses catastrophic complications resulting from an inappropriate antibiotic prescription for sinusitis.
Chen SI, Fox ER, Hall K, et al. Health Aff (Millwood). 2016;35:798-804.
Drug shortages have been a persistent problem for several years and have been shown to affect patient safety. The Food and Drug Administration Safety and Innovation Act of 2012 was intended to address these shortages. This analysis found that while shortages have decreased since the act was passed, problems with drug supply for acute care facilities remain.
Reed BN, Fox ER, Konig M, et al. Am Heart J. 2016;175:130-41.
Patients hospitalized with cardiovascular conditions are particularly vulnerable to medication errors. This review explains how drug shortages associated with cardiovascular medications pose risks to patients and provides recommendations for clinicians, policymakers, and manufacturers to address this problem.
Hawley KL, Mazer-Amirshahi M, Zocchi MS, et al. Acad Emerg Med. 2016;23:63-69.
This analysis of medication shortages in the emergency department revealed that there have been shortages of high-acuity medications for which no substitute is available. This suggests further investigation into patient safety implications of drug shortages is needed.
Fox ER, Sweet B, Jensen V. Mayo Clin Proc. 2014;89:361-73.
National drug shortages in the United States have become a serious patient safety concern. Spotlighting the impact of drug shortages on the economy and health care, this review reveals underlying issues contributing to the problem and highlights the persisting need for solutions to address them.
Hersh AL, Shapiro DJ, Pavia AT, et al. Pediatrics. 2011;128:1053-61.
Prescribing of antibiotics for non-bacterial illnesses remains very common in outpatient pediatrics. Unnecessary antibiotic prescribing can be associated with serious patient safety consequences, as discussed in an AHRQ WebM&M commentary.
Sharek PJ, McClead RE, Taketomo C, et al. Pediatrics. 2008;122:e861-e866.
This AHRQ-funded study describes the implementation of an Institute for Healthcare Improvement–style quality improvement collaborative aimed at reducing narcotic-related adverse drug events (ADEs). Fourteen participating hospitals adopted a series of recommended interventions while tracking ADE rates in a pre- and postintervention study design. Investigators discovered a 67% reduction in narcotic-related ADE rates, and also noted decreased rates of constipation and automated drug-dispensing overrides in patients receiving narcotic therapy. The authors point out several limitations to the study, including the inability to measure compliance with the intended change packages at each hospital. This study provides a nice example of the challenges in evaluating multifaceted quality improvement interventions despite its successful outcomes.
Sharek PJ, Horbar JD, Mason W, et al. Pediatrics. 2006;118:1332-40.
Triggers, clinical signals that may indicate adverse events (AEs), have been used to screen for errors in a variety of clinical settings. This AHRQ–funded study used methodology similar to a prior study in adult intensive care unit patients to develop a chart-based set of triggers for error identification in the neonatal intensive care unit (NICU). Through an expert consensus process, 17 triggers were identified and used to screen charts from 15 NICUs. Adverse events were relatively common, occurring at a rate of 0.74 per patient, most of which were preventable. The trigger tool appeared to be a sensitive (though nonspecific) method for identifying AEs. Use of this chart-based review process may help identify specific patient populations at high risk for AEs and help target patient safety efforts.