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 70 Results

Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable

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WebM&M Case September 27, 2023

A 14-year-old girl was admitted to the hospital with a new diagnosis of type 1 diabetes mellitus without ketoacidosis. Before discharge, medications intended for home use were delivered to the patient’s bedside, but the resident physician noticed a discrepancy. An insulin pen and pen needles had been ordered, but an insulin vial and extra insulin syringes were delivered. Neither the patient nor the parents had received education on how to draw up and administer insulin using a vial and syringe.

Drug shortages.

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Aronson JK, Heneghan C, Ferner RE. Br J Clin Pharmacol. Epub 2023 Jul 16.

Addressing drug shortages is a patient safety priority. Part One of this review summarizes existing definitions for drug shortages and the harms that can occur due to drug shortages (e.g., medication errors, treatment delays, undertreatment). Part Two discusses trends in drug shortages, the causes of drug shortages, and potential solutions.

Nearly all hospital pharmacists say drug shortages are negatively impacting care; a third say impacts are ‘critical.’

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McPhillips D. CNN. August 10, 2023.

Drug shortages present clinicians and patients with numerous challenges. This news story discusses the extensive presence of medication shortages through the experience of health system pharmacists. It quantifies the impacts of drug shortages on effective care as they contribute to the delay, cancelation, or rationing of needed treatments.

Drugmakers are abandoning cheap generics, and now US cancer patients can’t get meds.

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Allen A. KFF Health News. June 21, 2023.

A variety of supply-chain, quality control, and economic factors complicate access to medications due to drug shortages that put patients at risk. This article discusses specific systemic weaknesses in the drug development process that are reducing the safety of cancer medication therapy in the United States.

As cancer drug shortages grow, some doctors are forced to ration doses or delay care.

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Kopf M, Beck C. NBC News. May 26, 2023.

Lack of access to appropriate cancer medications can be particularly difficult for patients and clinicians. This news article discusses the current shortage of chemotherapy drugs, the psychological and physical harm potential in the situation and what should be done to improve medication supply.

Cancer drug shortages are creating dire circumstances for some patients.

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Lovelace B, Jr, Kopf M. NBC. April 11, 2023.

Shortages of life-saving cancer drugs have been a problem for many years and were exacerbated by the COVID-19 pandemic. This news article reports that low profitability of manufacturing generic drugs contributes to this shortage. Until these cancer drugs are available, many patients will receive no treatment, or treatment that is less than ideal.

Improving safety by evaluating the impact of the supply chain and drug shortages on health-systems.

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Patel V, Cieslak K, Hertig JB. Hosp Pharm. 2023;58:120-124.

Supply chain vulnerabilities can lead to equipment and drug shortages which can result in adverse events; the COVID-19 pandemic only exacerbated these problems. This review explains what makes the healthcare supply chain vulnerable and suggests potential solutions.

Medical middlemen: broken system making it harder for hospitals and patients to get some life-saving drugs.

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Whitaker B. CBS News. May 22, 2022.

Drug shortages represent a complex system level challenge in health care that can harm patients. This news segment details economic and production factors that affect the availability of generic medications. Clinicians and families were interviewed to share tactics for managing these situations to support patient safety despite shortages.

Nearly all thirty most frequently used emergency department drugs experienced shortages from 2006-2019.

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Lin MP, Vargas-Torres C, Shin-Kim J, et al. Am J Emerg Med. 2022;53:135-139.

Drug shortages can result in patient harm, such as dosing errors from a medication substitution. In this study, 28 of the 30 most frequently used medications in the emergency department experienced shortages between 2006 and 2019. The most common reasons for shortages were manufacturing delays and increased demand. The COVID-19 pandemic exacerbated pre-existing drug shortages.

AHRQ PSNet Annual Perspective: Impact of the COVID-19 Pandemic on Patient Safety

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Perspective on Safety March 30, 2021

In this PSNet Annual Perspective, we worked with co-authors Dr. Jacqueline C. Stocking, a quality improvement and critical care specialist, and Dr. Christian Sandrock, a patient safety professional and emerging infectious diseases specialist, to provide a look at news and research related to the impact of the COVID-19 pandemic on patient safety.

Drug shortages amid the COVID-19 pandemic.

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Bookwalter CM. US Pharmacist. 2021;46(2):25-28.

COVID-19 has increased uncertainties in sectors across health care. This article discusses a variety of supply-chain factors that impact medication availability. The author suggests roles for pharmacists in antibiotic stewardship and policy implementation to manage shortages safely.

Vulnerability of the medical product supply chain: the wake-up call of COVID-19.

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Miller FA, Young SB, Dobrow M, et al. BMJ Qual Saf. 2020;30:331-335.

The COVID-19 pandemic has raised concerns about medical product shortages and demand surges, and the resulting effects on patient safety. This viewpoint discusses medical product supply chain vulnerabilities heightened by the COVID-19 pandemic. The authors summarize the evidence on supply chain resilience and medical product shortage, provide examples to illustrate key vulnerabilities, and discuss reactive and proactive solutions for medical product shortage.

Impact of the COVID-19 pandemic on cancer care: a global collaborative study.

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Jazieh AR, Akbulut H, Curigliano G, et al. JCO Glob Oncol. 2020;6):1428-1438.

Patients with chronic health needs, including those with cancer, and their providers face numerous challenges during the COVID-19 pandemic. Survey results from 356 health care centers across 54 countries indicate that the impact of the COVID-19 pandemic on cancer care is widespread. Many centers reported challenges in delivering care, reduction in services, lack of personal protective equipment, staffing shortages, and limited access to medications. Respondents also reported potential patient harm due to interruptions in cancer-specific and non-cancer care.

National drug shortages worsen during COVID-19 crisis: proposal for a comprehensive model to monitor and address critical drug shortages.

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Piatek OI, Ning JC-min, Touchette DR. Am J Health Syst Pharm. 2020;7:1778-1785.

Drug shortages are an ongoing threat to safe patient care. This commentary discusses the impact of COVID-19 on medication supply and demand, and the resulting drug shortages. The authors provide several recommendations for reducing future drug shortages in times of crises, including increasing stockpiles and creating a critical drug list with potential substitutes.

Global drug shortages due to COVID-19: impact on patient care and mitigation strategies.

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Badreldin HA, Atallah B. Res Social Adm Pharm. 2020;17:1946-1949.

This article discusses global drug shortages due to the COVID-19 pandemic, the impact on patient outcomes and the role of pharmacists and policymakers in mitigating emerging drug shortages related to the pandemic.

Special report: COVID deepens the other opioid crisis - a shortage of hospital painkillers.

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Girion L, Levine D, Respaut R. Reuters. 2020;June 9.

The COVID-19 pandemic has disrupted the supply of protective equipment, medical devices and medications. This article discusses how economics contribute to drug shortages and highlights the specific impact on access to the opioids essential for providing safe care for hospitalized patients with COVID-19.

Medication Safety During the COVID-19 Pandemic: What Have We Learned in the United States.

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Institute for Safe Medication Practices and US Food and Drug Administration Division of Drug Information. June 23, 2020.

The COVID-19 pandemic response is creating a need for care delivery adjustments that include changes in pharmacy and medication practices. This webinar discussed process alterations that have the potential to impact safe medication administration and provide context for the changes to help ensure they are effectively implemented.

Ensuring access to medications in the US during the COVID-19 pandemic.

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Alexander GC, Qato DM. JAMA. 2020;324:31-32.

The COVID-19 pandemic has raised concerns about the pharmaceutical supply chain, from overseas manufacturing to medication distribution within the United States. This commentary presents several emergency response and preparedness measures for policymakers, pharmaceutical distributors and pharmacies to prepare for drug shortages and demand surges. Suggested measures include developing an “essential medicines” strategy, using allocation strategies that prevent stockpiling and drug shortages and expanding capacity for mail-order and home delivery.

Spikes in demand from coronavirus patients are creating shortages of asthma drugs and sedatives for ventilator patients.

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Rowland C, Slater J. Washington Post. April 12, 2020.

Drug shortages are a persistent system-level challenge to patient safety. This story highlights the residual impact of medication unavailability due to heightened pressure for medications to enable effective ventilation of patients with COVID-19.

Mounting drug shortages delay treatments for patients with bladder cancer

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Tirrell M, Taylor H. CNBC. November 27, 2019.

Drug shortages are associated with increased medication errors and longer length of stays that increase risks to patients. This story examines how the issues affect cancer patients and suggests avenues for improvement.

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