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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 - 20 of 35 Results

Pharmacy Practice News Special Edition. December 13, 2022: 43-54.

Medication errors continue to occur despite long-standing efforts to reduce them. This article summarizes types of errors submitted to the Institute for Safe Medication Practices reporting program in 2021. The piece discusses the medications involved, recommendations for improvement, and technologies to be employed to minimize error occurrence.
Sutherland A, Jones MD, Howlett M, et al. Drug Saf. 2022;45:881-889.
Intravenous (IV) medication smart pumps can improve medication administration, but usability issues can compromise safety. This article outlines strategic recommendations regarding the implementation of smart pump technology to improve patient safety. Recommendations include standardization of infusion concentrations, improving drug libraries using a human-centered approach, and increasing stakeholder engagement.

ISMP Medication Safety Alert! Acute care edition. October 20, 2022;20(21):1-5.

Errors due to inadequate information use with intravenous smart pumps are a safety concern. This article discusses factors that contribute to medication errors and smart pumps, which include out-of-date drug libraries, omitted dose limits, and variable rate infusions. Recommendations for improvement include the creation, testing, and updating of drug libraries.
Sutherland A, Gerrard WS, Patel A, et al. BMJ Open Qual. 2022;11:e001708.
Smart pump software can improve medication safety but can also introduce patient safety hazards, such as alert fatigue. In this study, dose error reduction software (DERS) was implemented across two large UK National Health Service (NHS) institutes for one year. Findings indicate that compliance with DERS was 45%, but across one year of implementation, severe harm or death was avoided in up to 110 patients.
Messing EG, Abraham RS, Quinn NJ, et al. Am J Nurs. 2022;122.
When hospitals began to fill up with COVID-19 patients, new strategies had to be developed and implemented quickly to reduce the spread of the virus. This article describes one strategy implemented by a New York hospital: relocating smart intravenous (iv) infusion pumps outside of patient rooms. Challenges, facilitators, and lessons learned are discussed.
Marufu TC, Bower R, Hendron E, et al. J Pediatr Nurs. 2022;62:e139-e147.
Medication errors threaten patient safety and can result in adverse outcomes. This systematic review identified seven types of nursing interventions used to reduce medication administration errors in pediatric and neonatal patients: education programs, medication information services, clinical pharmacist involvement, double checking, barriers to reduce interruptions during drug calculation and preparation, use of smart pumps, and improvement strategies (e.g., checklists, process or policy changes). Meta-analysis pooling results from various types of interventions demonstrated a 64% reduction in medication administration errors.
Wei W, Coffey W, Adeola M, et al. Am J Health Syst Pharm. 2021;78:s105–s110.
Smart pumps can improve medication safety, but barriers such as workarounds and alert fatigue can limit their effectiveness. After implementing smart pumps with an electronic health record (EHR) system, this community hospital saw increased drug library compliance and fewer infusions generating alerts.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; August 20, 2021.
This announcement seeks to raise awareness of the potential risks associated with the use of robotic-assisted surgical devices in mastectomies or cancer-related care. Recommendations for patients who may seek to have robotically assisted surgery include asking about their surgeon's experience with these procedures and discussing benefits, risks, and alternatives regarding available treatment options with their health care provider. Suggestions for health care providers include completing specialized training on procedures they perform. A WebM&M commentary described the challenges and benefits associated with robotic surgery.
Ni Y, Lingren T, Huth H, et al. JMIR Med Inform. 2020;8:e19774.
Interoperability of smart pumps and electronic health record (EHR) systems can improve clinical data accuracy. This study evaluated the utility of harmonizing EHR data and smart pump records (SPRs) in detecting medication administration errors in one neonatal intensive care unit (NICU). The authors found that compared with medication administration records, dosing discrepancies were more commonly detectable using integrated SPRs, which suggests that this approach may be a more reliable data source for medication error detection.
Waterson J, Al-Jaber R, Kassab T, et al. JMIR Hum Factors. 2020;7:e20364.
Smart pumps are considered a valuable method to improve medication safety. This study used smart pump medication logs and reporting software to identify cancelled infusions and resolutions of infusions alerts to characterize near-miss infusion pump errors. The study identified a high number of lookalike-soundalike near-miss errors. Analyses indicate that incorrect medication and wrong dose selections account for approximately 22% of all cancelled infusions.
Kirkendall ES, Timmons K, Huth H, et al. Drug Saf. 2020;43:1073-1087.
This systematic review catalogued and mapped the types of human errors related to smart pumps and associated error-prevention strategies. Error categories included (1) undocumented errors, (2) drug library errors, (3) programming errors, (4) administration errors, and (5) ancillary equipment errors. The authors mapped these errors to existing, standardized medication error classification and found that some errors (e.g., drug library errors) are introduced by the implementation of smart pump technology and some may be the result of workarounds. A range of prevention strategies were identified and mapped to the error types. These findings can serve as a toolkit for clinical use and development of best practices.  
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.
Rodriguez-Gonzalez CG, Herranz-Alonso A, Escudero-Vilaplana V, et al. J Eval Clin Pract. 2019;25:28-35.
Pharmacy robots are now commonly used in hospitals for dispensing medications. Conducted at a Spanish hospital, this study found that use of pharmacy robots reduced medication dispensing errors and improved staff efficiency. The role of a pharmacy robot in a serious medication error is explored in a book that examined the effects of technological change on the health care system.

Loh E. BMJ Leader. 2018;2(2):59-63.

Artificial intelligence (AI) can improve diagnostic accuracy. Despite early enthusiasm for the utility of AI at the front line, some have raised concerns associated with legal liabilities and ethical issues. This review discusses these considerations and suggests approaches that leaders and clinicians should embrace to prepare for future integration of AI systems in practice.

The Economist. June 7, 2018.

Artificial intelligence (AI) can improve the timeliness and accuracy of decision making in health care. This magazine article reports on how AI use in medicine can affect diagnosis of cancers, stroke, and cardiac arrhythmia. The piece underscores that though these improvements may look impressive, human knowledge will still be necessary to achieve the full benefit of AI applications for health care improvement.
Ho A, Quick O. BMC Med Ethics. 2018;19:18.
Although use of smart technologies for self-diagnosis and care management offers patients convenience, cost-savings, and expediency, they may also contribute to poor decision-making and harm. This commentary explores the impact of direct-to-consumer monitoring devices and smartphone applications on care and the therapeutic relationship. The authors advocate for regulation and assessment regarding accuracy of these tools.
Mira JJ, Carrillo I, Guilabert M, et al. J Med Internet Res. 2017;19.
Investigators implemented a website in a Spanish health care system that was designed to provide information about the second victim phenomenon and help support those involved. The website was well received by health care professionals and patient safety managers.
Ratanawongsa N, Chan LLS, Fouts MM, et al. J Diabetes Res. 2017;2017:8983237.
Diabetes medications are known to be high risk for adverse drug events. This case study reviews several patient safety measures for electronic prescribing for diabetes in outpatient care. Researchers describe an adverse drug event involving electronic prescribing of insulin and detail how the incident could have been prevented. Electronic prescribing is not currently standardized and may require using a trade name for medications, which may lead to prescribing errors. Adoption of the medication naming conventions put forth by the National Library of Medicine's RxNorm would prevent this vulnerability. Similarly, standardizing electronic prescribing orders for high-risk medications like insulin may reduce the risk of erroneously choosing a long-acting instead of short-acting insulin formulation, which can have life-threatening consequences. The authors advocate for using Universal Medication Schedule instructions and providing language-concordant labels to patients to support safe medication self-administration. They suggest that real-time, bidirectional communication between prescribers and pharmacists may improve safe prescribing. The authors conclude that recommended safety practices are not uniformly implemented in clinical practice and advocate for implementation research to ensure medication safety for outpatients with diabetes.
Tarola CL, Quin JA, Haime ME, et al. JAMA Surg. 2016;151:1183-1186.
Communication breakdowns in the operating room are associated with preventable adverse events. This study examined the potential of a novel workflow management system—a computerized system which used voice recognition and built-in algorithms to ensure important procedural steps were undertaken appropriately—to improve patient safety. The system was able to detect when intraoperative tasks were being performed and successfully identified omitted steps as well.
Alemzadeh H, Raman J, Leveson N, et al. PLoS One. 2016;11:e0151470.
Using an automated natural language processing tool, this retrospective study evaluated adverse events related to robotic surgery reported between 2000 and 2013. Device malfunctions contributed to many incidents, thus understanding these technical difficulties will be important for avoiding future harms.