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 132 Results

Lessons learned in implementing a chronic opioid therapy management system.

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Carlile N, Fuller TE, Benneyan JC, et al. J Patient Saf. 2022;18:e1142-e1149.

The opioid epidemic has prompted national and institutional guidelines for safe opioid prescribing. This paper describes the development, implementation, and sustainment of a toolkit for safer opioid prescribing for chronic pain in primary care. The authors describe organizational, technical, and external barriers to implementation along with attempted solutions and their effects. The toolkit is available as supplemental material.

Toolkit To Improve Antibiotic Use in Ambulatory Care.

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Rockville, MD: Agency for Healthcare Research and Quality; October 2022.

Inappropriate antibiotic prescribing is associated with increased risk potential. This toolkit assists in simplifying the antibiotic decision-making process. It is organized around a four-point decision aide and contains resources on using a stewardship program, communicating about prescribing and applying best practices for common infectious diseases.

Recommendations for the safety of hospitalised patients in the context of the COVID-19 pandemic: a scoping review.

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Martins MS, Lourenção DC de A, Pimentel RR da S, et al. BMJ Open. 2022;12:e060182.

In early 2020, hospitals, organizations, and expert panels released recommendations to maintain patient safety while reducing spread of COVID-19. This review summarized safety recommendations from 125 studies, reviews, and expert consensus documents. Recommendations were categorized into one of four areas: organization of health services, management of airways, sanitary and hygiene measures, and management of communication. Planning and implementing best practices based on these recommendations ensure safe care during COVID-19 and future pandemics.

Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan.

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WebM&M Case September 28, 2022

This case describes a 20-year-old woman was diagnosed with a pulmonary embolism and occlusive thrombus in the right brachial vein surrounding a peripherally inserted central catheter (PICC) line (type, gauge, and length of time the PICC had been in place were not noted). The patient was discharged home but was not given any supplies for cleaning the PICC line, education regarding the signs of PICC line infection, or referral to home health services.

Effect of a pharmacy-based centralized intravenous admixture service on the prevalence of medication errors: a before-and-after study.

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Jessurun JG, Hunfeld NGM, Van Rosmalen J, et al. J Patient Saf. 2022;18:e1181-e1188.

Intravenous admixture preparation errors (IAPE) in hospitals are common and may result in harm if they reach the patient. In this before-and-after study, IAPE data were collected to evaluate the safety of a pharmacy-based centralized intravenous admixture service (CIVAS). Compared to the initial standard practice (nurse preparation on the ward), IAPE of all severity levels (i.e., potential error, no harm, harm) decreased and there were no errors in the highest severity level after implementation of CIVAS.

Toward safer opioid prescribing in HIV care (TOWER): a mixed-methods, cluster-randomized trial.

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Cedillo G, George MC, Deshpande R, et al. Addict Sci Clin Pract. 2022;17:28.

In 2016, the Centers for Disease Control (CDC) issued an opioid prescribing guideline intended to reverse the increasing death rate from opioid overdoses. This study describes the development, implementation, and effect of a safe prescribing strategy (TOWER) in an HIV-focused primary care setting. Providers using TOWER were more adherent to the CDC guidelines, with no worsening patient-reported outcome measures.

Management of Cardiac Arrest in Unconventional Locations.

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WebM&M Case May 16, 2022

This WebM&M describes two cases involving patients who became unresponsive in unconventional locations – inside of a computed tomography (CT) scanner and at an outpatient transplant clinic – and strategies to ensure that all healthcare teams are prepared to deliver advanced cardiac life support (ACLS), such as the use of mock codes and standardized ACLS algorithms.

Fast tracking in cardiac surgery: is it safe?

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MacLeod JB, D’Souza K, Aguiar C, et al. J Cardiothorac Surg. 2022;17:69.

Post-operative complications can lead to increased length of hospital stay, cost, and resource utilization. This retrospective study compared “fast track” patients (patients extubated and transferred from ICU to a step-down unit the same day as their procedure) and patients who were not fast tracked. Results showed fast track pathways led to a reduction in ICU and overall hospital length of stay and similar post-operative outcomes.

Maternity Pre-arrival Instructions by 999 Call Handlers.

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Farnborough, UK: Healthcare Safety Investigation Branch; February 17, 2022.

Pre-hospital emergency care can be vulnerable to timing, information, and task failures that compromise safety. This investigation explores how computerized decision support system access played a roles in an emergency call-center program incident where erroneous information was transmitted to a pregnant patient that contributed to infant harm.

Three new best practices in the 2022-2023 Targeted Medication Safety Best Practices for Hospitals.

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ISMP Medication Safety Alert! Acute care edition. February 10, 2022:27(3):1-6.

Best practices evolve over time, given experience and evidence associated with their use. This article summarizes 3 new areas of focus included in current recommendations for sustaining medication safety. The new practices focus on improving the safety of oxytocin use, enhancing vaccine administration through bar coding, and implementing multifocal efforts to reduce high-alert medication errors. A survey accompanies the article to gather data on the presence of the new recommendations in the field.

Curated Libraries

Maternal Safety

September 13, 2021

Ensuring maternal safety is a patient safety priority. This library reflects a curated selection of PSNet content focused on improving maternal safety. Included resources explore strategies with the potential to improve maternal care delivery and outcomes, such as high reliability, collaborative initiatives, teamwork, and trigger tools.

Implementing universal suicide risk screening in a pediatric hospital.

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Sullivant SA, Brookstein D, Camerer M, et al. Jt Comm J Qual Patient Saf. 2021;47:496-502.

Improving screening for suicidal ideation is an important patient safety priority. This article describes the implementation and evaluation of a hospital-wide program to identify teenagers at elevated risk for suicide and to connect them with services. During the first year of implementation, over 138,000 screenings were completed and 6.8% of screens were positive for elevated risk.

Stroke hospitalization after misdiagnosis of "benign dizziness" is lower in specialty care than general practice: a population-based cohort analysis of missed stroke using SPADE methods.

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Chang T-P, Bery AK, Wang Z, et al. Diagnosis (Berl). 2022;9:96-106.

A missed or delayed diagnosis of stroke increases the risk of permanent disability or death. This retrospective study compared rates of misdiagnosed stroke in patients presenting to general care or specialty care who were initially diagnosed with “benign dizziness”. Patients with dizziness who presented to general care were more likely to be misdiagnosed than those presenting to specialty care. Interventions to improve stroke diagnosis in emergency departments may also be successful in general care clinics.

Intravenous admixture preparation considerations, Parts 9-A and 9-B: error prevention in intravenous admixture preparation.

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Allen LV, Jr. Int J Pharm Compd. 2021;25:131-139; 222-229.

Intravenous admixture compounding is a complex activity that harbors risks for patients and health care staff. This two-part series reviews the types of errors that compromise the safety of compounding practices, steps in the process where they occur and prevention tactics.

Leaving a discontinued FentaNYL infusion attached to the patient leads to a tragic error

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ISMP Medication Safety Alert! Acute care edition. 2021;26(13);1-2.

High-alert medication misadministration is of great concern due to the increased opportunity for harm associated with mistakes. This case describes how tubing and alarm management errors came together to result in the death of patient sedated with fentanyl.

COVID-19: an emerging threat to antibiotic stewardship in the emergency department.

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Pulia M, Wolf I, Schulz L, et al. West J Emerg Med. 2020;21:1283-1286.

Antimicrobial stewardship is one strategy to improve antibiotic use to reduce hospital-acquired infections. In this editorial, the authors discuss negative effects of COVID-19 on antimicrobial resistance and antibiotic stewardship in the emergency department (ED) and approaches for optimizing ED stewardship during the pandemic.

Streamlining care in crisis: rapid creation and implementation of a digital support tool for COVID-19.

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Stark N, Kerrissey M, Grade M, et al. West J Emerg Med. 2020;21:1095-1101.

This article describes the development and implementation of a digital tool to centralize and standardize COVID-19-related resources for use in the emergency department (ED). Clinician feedback suggests confirms that the tool has affected their management of COVID-19 patients. The tool was found to be easily adaptable to accommodate rapidly evolving guidance and enable organizational capacity for improvisation and resiliency.

Team-based approach to improving medication reconciliation rates in family medicine residency clinics.

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Harper PG, Schafer KM, Van Riper K, et al. J Am Pharm Assoc (2003). 2021;61:e46-e52.

This article describes a systematic team-based care approach to medication reconciliation implemented in four family medicine residency clinics. After implementation, there was a significant increase in the number of visits with physician-documented medication reconciliation and this increase was sustained one year later.

Catheter-associated urinary tract infection reduction in a pediatric safety engagement network.

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Foster CB, Ackerman K, Hupertz V, et al. Pediatrics. 2020;146:e20192057.

This article describes the implementation and results of catheter-associated urinary tract infection (CAUTI) prevention efforts by a large network of children’s hospitals between 2011 and 2017. Prevention efforts included catheter insertion and maintenance bundles. After implementation of the bundles, CAUTI rates across the network decreased by 61.6%.

Expanding frontiers of risk management: care safety in nursing home during COVID-19 pandemic.

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Scopetti M, Santurro A, Tartaglia R, et al. Int J Qual Health Care. 2021;33:mzaa085.

This article presents a COVID-19 infection prevention and control plan for nursing homes, emphasizing protections for healthcare professionals, prevention of infection spread among residents, management of COVID-19 cases and limiting access to visitors.

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