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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 - 19 of 19 Results
Mital R, Lovegrove MC, Moro RN, et al. Pharmacoepidemiol Drug Saf. 2022;31:225-234.
Accidental ingestion of over-the-counter (OTC) cold and cough medicines (CCMs) among children can result in adverse events. This study used national surveillance data to characterize emergency department (ED) visits for harms related to OTC CCM use and discusses differences by patient demographics, intent of use, and concurrent substance use.
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.
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.
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.
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.
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.
Cohen AL, Budnitz DS, Weidenbach KN, et al. J Pediatr. 2008;152:416-421.
J Pediatr … Medication misadventures leading to emergency … prevent unintentional overdoses in toddlers. … Cohen AL, Budnitz DS, Weidenbach KN, et al. National surveillance of … children and adolescents [published correction appears in J Pediatr. 2008 Jun;152(6):893].  J Pediatr . …
Budnitz DS, Pollock DA, Weidenbach KN, et al. JAMA. 2006;296:1858-66.
This study reports data from the National Electronic Injury Surveillance System, a representative sample of 63 hospitals that provide data on emergency department (ED) visits for injuries, poisonings, and adverse drug events (ADEs). Based on these data, the authors estimate that ADEs result in more than 700,000 ED visits yearly, most commonly due to allergic reactions or unintentional overdoses. ADEs were most common and most severe among the elderly, who were at significantly higher risk for both ED visits and hospitalization, confirming previous findings. As demonstrated in prior research, insulin and warfarin were the most common medications associated with ADEs requiring hospitalization. In this study, those drugs and digoxin accounted for nearly one-third of ADEs requiring hospitalization among the elderly. Thus, safety interventions targeting these medications could effectively reduce the burden of ADEs. 
Budnitz DS, Pollock DA, Mendelsohn AB, et al. Ann Emerg Med. 2005;45:197-206.
This project studied the epidemiologic viability of using an injury surveillance system to track outpatient adverse drug events (ADEs) treated in hospital emergency departments. The authors found that the system could play a useful role in helping to understand outpatient ADEs, identifying areas for research, and monitoring ADE prevention.