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.

Search All Content

Clear all filter(s)

Displaying 1 - 20 of 720 Results

Pediatric ADHD medication errors reported to United States poison centers, 2000 to 2021.

Save to Library

DeCoster MM, Spiller HA, Badeti J, et al. Pediatrics. 2023;Epub Sep 18.

Data from the National Poison Data System is useful for describing characteristics and trends of out-of-hospital medication errors. This retrospective study describes trends in therapeutic errors involving attention deficit/hyperactivity disorder (ADHD) medications as reported to poison control centers in the United States. From 2000 to 2021, errors increased by 300%, with more than half classified as "inadvertently took or was given medication twice." Although no deaths were reported and less than 5% resulted in moderate or major medical outcomes, increased patient and caregiver education and child-resistant medication containers are needed.

Barriers and facilitators associated with the implementation of surgical safety checklists: a qualitative systematic review.

Save to Library

Paterson C, Mckie A, Turner M, et al. J Adv Nurs. 2023;Epub Sep 7.

Effective implementation of the WHO Surgical Safety Checklist remains challenging. This qualitative synthesis of 34 studies identified several factors that influence uptake and compliance with the Surgical Safety Checklist, including effective leadership and use of audit and feedback.

Development of a proactive process to harmonize policy, infusion pump library, and electronic health record entries for continuous infusions at an academic medical center.

Save to Library

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.

Perceptions and attitudes of pediatricians and families with regard to pediatric medication errors at home.

Save to Library

de Dios JG, Lopez-Pineda A, Juan GM-P, et al. BMC Pediatr. 2023;23:380.

Children are at-risk for medication errors in the home setting, but no single database exists to collect these errors. This study compared parent and pediatrician perspectives on home medication safety for children aged 14 and under. Approximately 80% of pediatricians thought parents consulted the internet for information about their child's care and medications, and an equal percent of parents reported consulting their healthcare provider. Both groups reported lack of parental knowledge as the main contributor to medication errors, and most pediatricians supported the idea of a mechanism for collecting parent-reported errors and a learning system to support family engagement in medication error prevention.

Protocolization of analgesia and sedation through smart technology in intensive care: improving patient safety.

Save to Library

Ojeda IM, Sánchez-Cuervo M, Candela-Toha Á, et al. Crit Care Nurs. 2023;43:30-38.

High-alert medications can cause serious patient harm if administered incorrectly. This article describes a quality improvement project to reduce medication errors involving high-alert sedative and analgesic medications in the intensive care unit (ICU) through use of protocolized and centralized smart intravenous infusion pump technology. Use of the protocolized software led to the interception of nearly 400 infusion-related programming errors.

Anesthesia Risk Alert program: a proactive safety initiative.

Save to Library

Lee B, Marhalik-Helms J, Penzi L. Jt Comm J Qual Patient Saf. 2023;49:441-449.

Perioperative and anesthesia care present unique patient safety challenges. This article describes the development and implementation of the Anesthesia Risk Alert (ARA) program, which promotes collaborative clinical decision-making and recommends risk mitigation strategies to address specific high-risk clinical scenarios. Since implementation began in 2019, ARA compliance has exceeded 90% and has reduced the rate of adverse events among certain high-risk patients, such as those with a high body mass index.

Sleep Deprivation Leads to Medication Error During Spinal Epidural Anesthesia.

Save to Library

WebM&M Case August 30, 2023

This case describes a 27-year-old primigravid woman who requested neuraxial anesthesia during induction of labor. The anesthesia care provider, who was sleep deprived near the end of a 48-hour call shift (during which they only slept for 3 hours), performed the procedure successfully but injected an analgesic drug that was not appropriate for this indication. As a result, the patient suffered slower onset of analgesia and significant pruritis, and required more prolonged monitoring, than if she had received the correct medication.

Handling injectable medications in anaesthesia: Guidelines from the Association of Anaesthetists.

Save to Library

Kinsella SM, Boaden B, El‐Ghazali S, et al. Anaesthesia. 2023;78:1285-1294.

Anesthesia provision is a high-risk practice. This guidance provides practical steps to ensure perioperative medication delivery is as safe as possible. This material recommends approaches for both clinicians and organizations to enable collaborative safety efforts in anesthesia, including prefilled syringes, standardization, and adherence to safe labeling practices.

Missed nursing care in emergency departments: a scoping review.

Save to Library

Duhalde H, Bjuresäter K, Karlsson I, et al. Int Emerg Nurs. 2023;69:101296.

Missed nursing care (MNC) refers to needed nursing care that is delayed, partially completed, or not completed at all, and can result in adverse events. This systematic review summarizes missed nursing care in emergency departments (ED). Causes of MNC include overcrowding and patients with complex care needs, which may result in medication errors, pressure injuries, or patient deterioration.

Incidence and severity of medication reconciliation discrepancies in trauma patients.

Save to Library

Dunbar EG, Massey AC, Lee YL, et al. Am Surg. 2023;89:3272-3274.

Medication reconciliation is an important care process anytime a patient transitions from one care setting to another, including emergency department to hospital admission. This study sought to determine the incidence of completed medication reconciliation for admitted trauma patients and the number of identified discrepancies. Of the 89 patients included in the study, more than a quarter did not receive an admission medication reconciliation (AMR), and of those with an AMR, 48% had at least one unintended discrepancy, indicating the importance of completing medication reconciliation for all admitted trauma patients.

Implementation of barcode medication administration (BMCA) technology on infusion pumps in the operating rooms.

Save to Library

Hogerwaard M, Stolk M, Dijk L van, et al. BMJ Open Qual. 2023;12:e002023.

Barcode medication administration (BCMA) technology is a useful tool to reduce medication administration errors (MAE) in the operating room. This study used a pre-post design to estimate the rate of MAE before and after BCMA implementation on infusion pumps. MAE were significantly reduced and up to 90% of errors were considered preventable, if the staff had utilized BCMA. Reasons for not using BCMA included unreadable barcodes, lack of time, and resistance to new processes.

Improving emergency medicine clinician awareness of prehospital-administered medications.

Save to Library

Kamta J, Fregoso B, Lee A, et al. Prehosp Emerg Care. 2023;Epub Jul 28.

Handoffs from emergency medical services (EMS) to the emergency department (ED) are vulnerable to communication errors due to the time-pressured environment. This study reports on the implementation of an electronic health record (EHR) tool that added pre-hospital medication administration to the ED triage note to reduce medication administration errors (MAE). Although most ED providers reported they "always" review the triage note, MAE rates did not improve following implementation.

Meta-analysis of medication administration errors in African hospitals.

Save to Library

Alemu W, Cimiotti JP. J Healthc Qual. 2023;45:233-241.

Medication administration is a complex process and prone to errors. This review was conducted to identify predictors and incidence of medication administration errors (MAE) in African hospitals. Most predictors were at the system level (e.g., work environment, interruptions), followed by patient and professional/provider factors. As the number of included studies was low (13 studies) and most came from one nation, additional studies are needed.

A Complicated Course: Severe Alcohol Withdrawal with Dexmedetomidine Infusion.

Save to Library

WebM&M Case July 31, 2023

This case describes a 65-year-old man with alcohol use disorder who presented to a hospital 36 hours after his last alcoholic drink and was found to be in severe alcohol withdrawal. The patient’s Clinical Institute Withdrawal Assessment (CIWA) score was very high, indicating signs and symptoms of severe alcohol withdrawal. He was treated with symptom-triggered dosing of benzodiazepines utilizing the CIWA protocol and dexmedetomidine continuous infusion.

Anticoagulation-associated adverse drug events in hospitalized patients across two time periods.

Save to Library

Fanikos J, Tawfik Y, Almheiri D, et al. Am J Med. 2023;136:927-936.

Anticoagulants are high-risk medications in both outpatient and inpatient settings. This study compared two time periods, both before and after implementation of anticoagulant safety programs, to assess changes in type, severity, root cause, and outcomes of adverse events in hospitalized patients. Despite numerous changes in procedures and technology, adverse events increased in the post-implementation period.

Antimicrobial residual drug error in the intensive care unit; a single blinded prospective observational study.

Save to Library

Jarrett P, Keogh S, Roberts JA, et al. Intensive Crit Care Nurs. 2023;77:103403.

As with all medications, delays in or underdosing of antimicrobials can result in unnecessarily long hospital stays. This study found that discarded antibiotic vials in the intensive care unit (ICU) contained residual drug remaining in the vial (median 3.7% error). This finding suggests patients may not be receiving the full prescribed dose.

Content analysis of nurses' reflections on medication errors in a regional hospital.

Save to Library

Issacs AN, Raymond A, Kent B. Contemp Nurse. 2023;59:202-213.

Despite widespread improvement efforts, medication administration errors (MAE) remain a patient safety problem. In this study, nurses at one Australian hospital provided a reflection as to why they believed an MAE occurred and these reflections were subsequently analyzed using a human factors framework. Individual characteristics, nature of the work, and physical environment factors were identified as contributing to MAE and represent areas for improvement.

Assessing the impact of a new pediatric healthcare facility on medication administration: a human factors approach.

Save to Library

Godin MR, Nasr AS. J Nurs Adm. 2023;53:331-336.

Hospital design has been associated with patient safety incidents. This study compared rates of medication administration errors in the pediatric unit of a new evidence-based design (EBD) hospital with rates at the older facility prior to moving to the EBD hospital. Despite implementing EBD, rates of distractions were lower at the older facility; “interruption by physician” was the only distraction type to improve in the new EBD hospital.

A hard look at hard stops and workarounds in the acute care setting.

Save to Library

ISMP Medication Safety Alert! Acute care edition. June 29, 2023;28(13);1-4.

Hard stops in the electronic medical record prevent continuation of ordering, dispensing, or administering an unsafe medication to a patient. This article presents system-level recommendations to effectively introduce hard stops such as including physicians and pharmacists in decision making to reduce risk of workarounds in the future.

Caregiver and clinician perspectives on discharge medication counseling: a qualitative study.

Save to Library

Carroll AR, Schlundt D, Bonnet K, et al. Hosp Pediatr. 2023;13:325-342.

Accurate dosing and administration of liquid medications to children can be difficult for parents or caregivers. In this study, family caregivers and clinicians described their experiences at hospital discharge relating to both general and liquid-specific medication counseling. Clinicians and caregivers both stated that teach-back protocols were helpful but inconsistently used. Caregivers were not always shown how to draw up liquid into the syringes leading to them feeling uncertain about giving the correct dose. Health literacy and speaking languages other than English were also described as challenges.

The PSNet Collection: All Content

Search All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

The PSNet Collection: All Content

Search All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site