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.
Hospitals, pharmacies, and organizations have developed numerous strategies to prevent look-alike/sound-alike medication mix-ups, but these errors continue to occur. This article suggests a human factors approach by changing the shape of the container for each medication class-type, thus reducing clinicians’ cognitive load. Importantly, drug manufacturers would need to agree on container shapes to prevent confusion when drugs are ordered from different suppliers.
Hsu K-Y, DeLaurentis P, Bitan Y, et al. J Patient Saf. 2019;15:e8-e14.
Smart infusion pumps store drug safety information, but this data must be periodically updated. This study demonstrated significant delays in updating the drug information for smart infusion pumps. These delays resulted in failure to alert for two high-risk medication cases, but neither case led to patient harm.
Rhodes A, Evans LE, Alhazzani W, et al. Crit Care Med. 2017;45:486-552.
This guideline reviews recommendations and best-practice statements from an international consensus committee on sepsis treatment and management to guide safe care for patients with sepsis or septic shock.
Nemeth CP, Nunnally M, Bitan Y, et al. J Patient Saf. 2009;5:114-21.
This study describes a scientific analysis for assessing medical devices by combining a hospital staff assisted by human factors with medical professionals versed in equipment assessment.
The authors analyzed secondary (piggyback) infusions at their institution to illustrate human factors vulnerabilities in the process that could contribute to medication delivery failures.