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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 - 9 of 9 Results
Schnock KO, Dykes PC, Albert J, et al. BMJ Qual Saf. 2017;26:131-140.
Medication errors associated with intravenous smart pumps are a safety concern. Because errors are not always reported, the magnitude of this problem has been unknown. In this study, direct observation of nurses using smart pumps revealed that 60% of medication infusions involved one or more errors, but actual harm to patients was rare. The most common errors involved incorrect infusion rates and workarounds like bypassing the smart pump. These results accentuate a need for improvements in smart pump design to enhance safety and usability. A previous WebM&M commentary describes consequences of an incorrect medication infusion.
Vanderveen T. Patient Saf Qual Healthc. November/December 2014;11:38-40,42-45.
Spotlighting the growing concern around alarm fatigue, this magazine article provides an overview of efforts to augment alarm management and offers recommendations for hospitals working to reduce unnecessary alarms, including eliciting insights from nursing staff about areas for improvement and performing direct observations in patient care settings to monitor frequency of alarms.
WebM&M Case May 1, 2009
… or immediately communicated to all concerned. … Tim Vanderveen, PharmD, MS … Vice President Center for Safety and … of Healthcare Organizations; 2008. [Available at] 6. Vanderveen TW, Crass R, Lewis SR, et al. Impact of multiple dosing units on …
Raschke RA, Gollihare B, Wunderlich TA, et al. JAMA. 2003;280.
An alert system triggered by 37 drug-specific adverse events was programmed into a 650-bed hospital information system. The investigators found that 53% of the alerts were valid ("true positives") and that 44% of these had been unrecognized by the prescribing physicians prior to notification. The authors conclude that computer alert systems can help prevent a wide range of adverse drug events. This study was one of the first to support the use of trigger systems to recognize and help prevent medication errors.