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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 - 11 of 11 Results
Verma AA, Trbovich PL, Mamdani MM, et al. BMJ Qual Saf. 2024;33:121-131.
Artificial intelligence and machine learning present both opportunities and threats to patient safety. This article highlights machine learning applications in quality improvement and patient safety (e.g., decision support) and practice considerations before deploying machine learning applications (e.g., presence of underlying biases). The authors provide several recommendations for optimizing implementation of machine learning applications in healthcare settings.
Emerging Classic
Review
Babu KM, Brent J, Juurlink DN.  N Engl J Med. 2019;380:2246-2255.
Reducing patient harm associated with the use of opioids to manage pain is a patient safety priority. This review discusses how to reduce risk of opioid misuse among three groups of patients: opioid-naive patients, patients on long-term opioid therapy, and those with a history of substance abuse. Strategies include disposal recommendations, tapering, and coprescribing of naloxone.
Gomes T, Tadrous M, Mamdani MM, et al. JAMA Netw Open. 2018;1:e180217.
Opioid use can increase risk of adverse drug events, including overdoses. Researchers utilized data from the Centers for Disease Control and Prevention to examine opioid-related deaths in the United States from 2001 to 2016. During this period, opioid-related deaths increased by nearly 350%. Overdose deaths occurred more among men than women and were most prevalent in patients aged 15 to 34 years. These findings raise concern regarding the increasing proportion of deaths associated with opioid use. The authors call for targeted prevention and harm reduction efforts among young adults to address the growing opioid-related harm in this group. A PSNet perspective discussed opioid overdose as a patient safety problem.
Busse JW, Craigie S, Juurlink DN, et al. CMAJ. 2017;189:E659-E666.
Opioid pain medications carry high risk for adverse drug events, and opioid misuse is a growing patient safety concern. This guideline provides recommendations to augment safe prescribing of these high-risk medications for patients with chronic noncancer pain.
Finkelstein Y, Macdonald EM, Gonzalez A, et al. Pediatrics. 2017;139.
Opioid-related harm is a critical patient safety priority. This case control study examined the risk of opioid overdose among children whose mothers were prescribed either opioids or nonsteroidal anti-inflammatory agents in the prior year. The cases were children aged 10 or younger who were hospitalized or died from opioid overdose, and the controls were children of the same age without overdose. Compared to the children without overdose, those who were hospitalized or died were more likely to have a mother who was prescribed opioids. Antidepressant prescription was also more common among mothers of children who experienced opioid overdose. The authors recommend specific practices for safe opioid use, including prescription of smaller quantities and secure storage of medications, which prior studies demonstrate are not yet routine. This study emphasizes the urgent need to enhance the safety of outpatient opioid use.
Govindarajan A, Urbach DR, Kumar M, et al. N Engl J Med. 2015;373:845-53.
The link between lack of sleep and subsequent medical errors served as an impetus for physician duty-hours reform. In trainee physicians, sleep loss is associated with attentional failures, but little is known about the relationship between attending physician performance and sleep loss. This retrospective cohort study examined outcomes of elective surgical procedures among attending surgeons who had worked after midnight on the previous night versus those who had not. The investigators found no differences in mortality, complications, or readmissions between procedures performed by surgeons with sleep loss compared to those without sleep loss, mirroring results of an earlier simulation study. This may be due to greater technical skill among attending surgeons, or the ability to cancel or postpone elective procedures as needed at times of fatigue. This study included many institutions, physicians, and procedure types, suggesting that short-term sleep deprivation might not be a high-yield safety target for attending surgeons.
Stall NM, Fischer HD, Wu F, et al. Medicine (Baltimore). 2015;94:e899.
This study established that unintentional medication discontinuation upon nursing home admission decreased over time, though this improvement could not be attributed to accreditation requirements for medication reconciliation or any other specific intervention. This study highlights the challenge of attributing safety improvements to specific policy or practice changes.
Jeffs L, Hayes C, Smith O, et al. Eval Health Prof. 2014;37:366-78.
An organization-wide patient safety program consisting of open access online educational modules, an online forum for communication, and a reward system, led to a significant increase in voluntary patient safety event reporting. The largest uptick was seen in near miss reporting, which nearly doubled following the intervention.
WebM&M Cases
WebM&M Case July 1, 2006
A patient presenting to the ED with chest pain was ruled out for MI, and discharged on an ACE inhibitor. Two weeks later, he returns with a critically elevated potassium level, has a cardiac arrest, and dies.
Cornish PL, Knowles SR, Marchesano R, et al. Arch Intern Med. 2005;165:424-9.
This prospective study compared admitting prescription medication orders with a comprehensive medication history obtained through interview. Investigators aimed to evaluate the differences between the two sets of medication lists to demonstrate the number of discrepancies. Results demonstrated that more than half of the study participants had at least one unintended discrepancy. The most common errors included ones of omission, and the majority of the errors led to no significant harm but some discomfort or clinical deterioration. The authors discuss the potential for intervention to reduce these types of medication errors and the role of pharmacists in assisting with accurate medication histories.