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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 355 Results
Khan WU, Seto E. J Med Internet Res. 2023;25:e43386.
Artificial intelligence (AI) and machine learning (ML) are emerging as tools to improve patient care, but they are not without risks. This article proposes use of a safety checklist to determine readiness to launch AI technologies, prompting users to consider physical and mental health and economic and social risks and benefits.
Ye J. JMIR Periop Med. 2023;6:e34453.
Perioperative medication errors are common. This article highlights several interventions to reduce the risk of perioperative medication errors, including improved medication labeling, adoption of artificial intelligence for decision support and risk prediction, and the use of health information technology (IT), such as computerized physician order entry (CPOE), electronic medication administration records (eMAR), and barcode medication administration (BCMA).
Kennedy GAL, Pedram S, Sanzone S. Safety Sci. 2023;165:106200.
Simulation training is an important component of medical education. In this study, researchers compared the impact of traditional clinical skills training with or without interactive virtual reality (VR) on human error among medical students performing arterial blood gas collection. Findings indicate that students who participated in VR-based clinical skills training were less likely to commit errors during simulated practical exam compared to students who did not participate in VR-based training.
Wolf M, Rolf J, Nelson D, et al. Hosp Pharm. 2023;58:309-314.
Medication administration is a complex process and is a common source of preventable patient harm. This retrospective chart review of 145 surgical patients over a two-month period found that 98.6% of cases involved a potential medication error, most frequently due to potential dose omissions and involving vasopressors, opioids, or neuromuscular blockers.
Denecke K. Stud Health Technol Inform. 2023;302:157-161.
The public is increasingly using conversational assistants like Siri, Alexa, and Google Assistant to find medical advice and self-diagnose. This narrative review summarizes three facets of safety: system (data privacy/security), patient (risks of acting on inaccurate information), and perceived (patient trust in the system). Future research should address all three safety facets, and the results should be transparent to consumers.

ISMP Patient Safety Alert! Acute care edition. May 18, 2023;28(10);1-3.

Dose error-reduction systems (DERS) and drug libraries are tools for use with smart infusion pumps to ensure safe intravenous medication administration. This article discusses infusion problems unrelated to user error that went undetected by the technology and reached patients. Recommendations to minimize similar occurrences include removing the involved device from service and investigating the incident.
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.
Larimer C, Sumner V, Wander D. Nutr Clin Pract. 2023;Epub Apr 19.
Medical lines, such as intravenous (IV), oxygen, or feeding tubes, provide lifesaving support but may also pose safety threats. Following a 2022 Food and Drug Administration safety communication regarding risk of strangulation by feeding tubes, researchers sought to determine if pediatric healthcare providers and caregivers were aware of the risk of medical line entanglement, and what, if any, type of education was provided to reduce the risk. Most providers were aware of the risk of entanglement, and 90% of caregivers reported their child had become entangled. However, less than 10% of caregivers received training to prevent such entanglements. Numerous comments from caregivers are provided, describing instances of entanglements and strategies they’ve used to prevent it.
Lyell D, Wang Y, Coiera E, et al. J Am Med Inform Assoc. 2023;30:1227-1236.
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.
Perspective on Safety April 26, 2023

This piece discusses surveillance monitoring of patients in low-acuity units of the hospital to prevent failure to rescue events, its difference from high-acuity continuous monitoring, and its potential applications in other settings.

This piece discusses surveillance monitoring of patients in low-acuity units of the hospital to prevent failure to rescue events, its difference from high-acuity continuous monitoring, and its potential applications in other settings.

Drs. Susan McGrath and George Blike discuss surveillance monitoring and its challenges and opportunities.

King CR, Shambe A, Abraham J. JAMIA Open. 2023;6:ooaf015.
Handoffs and transitions of care represent a vulnerable time for patients as important information must be shared and understood by multiple people. This study focuses on postoperative nurse handoffs, specifically regarding situational awareness and anticipatory guidance, and the role artificial intelligence (AI) could play in improving handoffs. Five themes were uncovered, including the importance of situational awareness and associated barriers, how AI could address those barriers, and how AI could result in new/additional barriers.
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.

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.
Rockville, MD: Agency for Healthcare Research and Quality. PA-21-266.
This funding opportunity will support collaborative learning strategies that enable individuals and organizations to employ rapid prototyping to engineer new approaches focused on improving diagnosis and treatment. This learning laboratory funding builds on prior initiatives to further improvements in patient safety. The project submission process is now closed.
Perspective on Safety November 16, 2022

Human factors engineering or ergonomics (HFE) is a scientific discipline broadly focused on interactions among humans and other elements of a system.

Human factors engineering or ergonomics (HFE) is a scientific discipline broadly focused on interactions among humans and other elements of a system.

Michelle Schreiber photograph

We spoke to Dr. Michelle Schreiber about measuring patient safety, the CMS National Quality Strategy, and the future of measurement. Michelle Schreiber, MD, is the Deputy Director of the Center for Clinical Standards and Quality and the Director of the Quality Measurement and Value-Based Incentives Group at the Centers for Medicare & Medicaid Services.

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.
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.
Giuliano KK, Blake JWC, Bittner NP, et al. J Patient Saf. 2022;18:553-558.
Intravenous (IV) smart pumps can improve medication administration safety, but usability issues can compromise that safety. This study compared actual use of smart pumps to the manufacturer’s requirements for operation. Adherence to requirements was low and the authors present several recommendations to smart pump manufacturers. The Institute for Safe Medication Practices issued guidelines for safe use of smart pumps that address several of these safety concerns.