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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 38 Results
Moran JM, Bazan JG, Dawes SL, et al. Pract Radiat Oncol. 2023;13:203-216.
Safety risks are present in oncology radiation therapy. This recommendation builds on existing intensity modulated radiation therapy (IMRT) standards to highlight the importance of interdisciplinary engagement, training, and technology implementation to ensure high quality, safe IMRT is delivered to patients.
Lyell D, Wang Y, Coiera E, et al. J Am Med Inform Assoc. 2023;Epub Apr 18.
Patients and healthcare providers rely on devices that use artificial intelligence or machine learning in diagnostics, treatment, and monitoring. This study utilizes adverse event reports submitted to the FDA's Manufacturer and Use Facility Device Experience (MAUDE) database for machine learning-enabled devices. Mammography was implicated in 69% of reports, and the majority were near-miss events.
Gray KD, Subramaniam HL, Huang ES. JAMA Pediatr. 2023;177:459-460.
Previous research has identified racial and ethnic discrepancies in pulse oximetry measurement which can lead to delays in diagnosis or treatment. This editorial discusses racial and ethnic biases in clinical algorithms and devices and two emerging approaches – photoacoustic imaging and polarized light oximetry – that have potential to address the racial and ethnic biases in pulse oximetry.
Grauer JS, Kana LA, Alzouhayli SJ, et al. Surgery. 2022;173:357-364.
Surgical fires, while rare, can result in the injury, permanent disability, or death of patients or healthcare workers. Between 2000 and 2020, 565 surgical fires resulting in injury were reported to the FDA’s Manufacturer and User Facility Device Experience (MAUDE) database. Fires were most likely to occur during upper aerodigestive tract and head and neck surgeries; these were also most likely to result in life-threatening injury.

Food and Drug Administration. February 23. 2023.

Mismatches of medical device connectors are known factors in therapeutic agent administration failures, despite efforts to redesign equipment and minimize their occurrence. This series of case studies drawn from reports submitted to the Food and Drug Administration illustrates a variety of misconnection scenarios to demonstrate situations that have a range of potential for patient harm.

Wicklund E. HealthLeaders. January 19, 2023.

Technologies both advance and challenge care safety. This article summarizes an annual analysis spotlighting health technology that may contribute to patient harm. Issues with home-based tools and single-use devices were underscored as priorities for improvement by both care organizations and equipment manufacturers.
Kramer DB, Yeh RW. JAMA. 2023;329:136-143.
The Food and Drug Administration (FDA) plays an important role in ensuring the safety of medical devices. In this cross-sectional study, researchers identified a high risk of future Class 1 FDA recall (the most serious recall designation, indicating serious risks to patient safety) among previously authorized devices (predicates) with prior Class 1 recalls.
Lipprandt M, Liedtke W, Langanke M, et al. BMC Nurs. 2022;21:264.
Hospital-level care at home can reduce cost and hospital readmissions, but adverse events still occur at levels similar to hospitals. This study explored adverse events related to home mechanical ventilation (HMV), in order to categorize causes and recommend solutions. Interventions for nurses (e.g., checklists) and manufacturers (e.g., alarm design) may improve HMV.
Quesenberry M. Patient Safety. 2022;4:6-9.
Medical devices intended to improve patient safety can unintentionally lead to patient harm. This patient safety alert draws attention to the risk of injury when hospital wheelchairs are used by staff, patients, or visitors who may not have training in safe use. Understanding the proper use of the wheelchair, particularly folding wheelchairs, is crucial to ensuring safety.
Serou N, Slight RD, Husband AK, et al. J Patient Saf. 2022;18:358-364.
Operating rooms are high-risk healthcare settings. This study reviewed serious surgical incidents occurring at large teaching hospitals in one National Health Service (NHS) trust. The authors outline several possible contributing factors (i.e., equipment and resource factors, team factors, work environment factors, and organizational and management factors) discuss recommendations for safer care.

Silver Spring, MD: US Food and Drug Administration; April 5, 2022.

The challenge of medical device sterilization has shifted the design of some products with disposable elements in order to reduce opportunities for human error that increase infection potential during reuse. The publication supports the complete adoption of disposable duodenoscopes or scope components as a safety measure.
Sosa T, Mayer B, Chakkalakkal B, et al. Hosp Pediatr. 2022;12:37-46.
Many medications and medical devices can result in preventable harm in pediatric patients. This article describes one hospital’s efforts to implement explicit, structured processes and huddles to increase situational awareness regarding high-risk therapies among the care team and family members. After implementation, the percentage of electronic health record (EHR) alerts correctly describing high-risk therapies increased from 11% to 96%.
Coldewey B, Diruf A, Röhrig R, et al. Appl Ergon. 2021;98:103544.
Medical devices without user-friendly interface designs may contribute to patient complications. This review explores problems in the use and design of mechanical ventilators that challenge safe use. The authors provide recommendations to product engineers to improve safe ventilator design.

Zipp R. Medical Tech Dive. October 18, 2021.

This article highlights systems influences that detract from the effectiveness of current methods of reporting recalled unsafe medical devices and raising awareness of recalls for clinicians, patients and families. Challenges highlighted include the use of paper-based notification systems and data reporting delays.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; August 20, 2021.

Delays in treatment due to device misuse or design flaws can result in patient harm. This recall announcement highlights the omission of instructions describing a distinct device feature that, if a surgeon is unaware of it, reduces emergent umbilical vein catheter placement safety. Two deaths have been reported due to problems with the device.
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.
Lalani C, Kunwar EM, Kinard M, et al. JAMA Intern Med. 2021;181:1217-1223.
Medical device-associated errors are common and often result in preventable patient harm. Based on medical device adverse event data reported to the FDA's Manufacturer and User Facility Device Experience (MAUDE), this study used natural language processing to identify events not classified as deaths even though the patient died. Findings suggest that approximately 17% of medical device events that resulted in death were classified in other categories.

Cumberlege J. London, England, Crown Copyright. July 8, 2020.

Implicit biases are known to affect the safety of health care. This analysis of the National Health Service (NHS) found weaknesses in NHS’ consideration of and response to women’s medication and medical device concerns. Among the recommendations submitted to improve patient centeredness and respect for patients are the establishment of central yet independent authority to serve as the conduit to address patient concerns and improve system safety accountability.