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 187 Results

People for Patient Safety.

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PULSE Center for Patient Safety Education & Advocacy. Second Monday of every month; 7:00 PM (eastern).

Patient advocates and caregivers play a valuable role in keeping patients safe. This reoccurring session provides a communication forum for individuals to discuss topics and shared experiences as they support patient safety. The next monthly session will be held June 12, 2023.

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

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Patient Safety Innovation May 31, 2023

Seeking a sustainable process to enhance their hospitals’ response to sepsis, a multidisciplinary team at WellSpan Health oversaw the development and implementation of a system that uses customized electronic health record (EHR) alert settings and a team of remote nurses to help frontline staff identify and respond to patients showing signs of sepsis. When the remote nurses, or Central Alerts Team (CAT), receive an alert, they assess the patient’s information and collaborate with the clinical care team to recommend a response.

Enhancing Support for Patients’ Social Needs to Reduce Hospital Readmissions and Improve Health Outcomes

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Patient Safety Innovation March 29, 2023

With increasing recognition that health is linked to the conditions in which a patient lives, health systems are looking for innovative ways to support recently discharged patients in their lives outside of the hospital. In a recent innovation, Prime Healthcare Services, Inc., which includes a network of 45 hospitals, provided social needs assessments and strengthened its partnerships with community agencies to support the health of high-needs patients after their discharge from the hospital.

Emergence of Application-based Healthcare

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Perspective on Safety August 5, 2022

This piece focuses on the emergence and use of digital applications (apps), app-based products and devices for healthcare, and the implications for patient safety.

In Conversation With... Francoise Marvel, MD

Francoise A. Marvel, MD, is an assistant professor of medicine within the Division of Cardiology at Johns Hopkins Hospital, codirector of the Johns Hopkins Digital Health Innovation Lab, and the chief executive officer (CEO) and cofounder of Corrie Health. We spoke with her about the emergence of application-based tools used for healthcare and the patient safety issues surrounding the use of such tools.

Curated Libraries

Medication/Drug Errors

January 14, 2022

The medication-use process is highly complex with many steps and risk points for error, and those errors are a key target for improving safety. This Library reflects a curated selection of PSNet content focused on medication and drug errors. Included resources explore understanding harms from preventable medication use, medication safety...

Potential for medication overdose with ENFit low dose tip syringe: FDA Safety Communication.

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MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; October 12, 2021.

This announcement highlights the possibility of medication administration inaccuracy due to design characteristics of a low dose tip (LDT) syringe. Recommended cleaning methods and other actions for patients, families and clinicians are provided to protect dose precision when using these syringes.

Patient Safety Article Collection.

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American Patient Rights Association. 2012-2018.

This resource collection highlights news items that examine the potential for patients to be put at risk for emotional, financial, or physical harm.

Adverse drug event-related admissions to a pediatric emergency unit.

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Carvalho IV, Sousa VM de, Visacri MB, et al. Pediatr Emerg Care. 2021;37:e152-e158.

This study sought to determine the rate of pediatric emergency department (ED) visits due to adverse drug events (ADE). Of 1,708 pediatric patients, 12.3% were admitted to the ED due to ADEs, with the highest rates of admission due to neurological, dermatological, and respiratory medications. The authors recommend the involvement of clinical pharmacists to prevent and identify ADEs in the pediatric population, particularly through education of children’s caregivers and health professionals.

Patient.

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Canadian Patient Safety Institute;

Patient stories and insights related to medical mishaps can inspire and motivate work to enhance health care safety. This annual podcast series uses patient accounts of medical errors to collaboratively explore solutions with health care providers.

COVID-19 can last for several months. The disease’s “long-haulers” have endured relentless waves of debilitating symptoms—and disbelief from doctors and friends.

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Young E. The Atlantic. 2020.

Preconceptions of disease can impact the medical and social response to patients with chronic conditions. This article discusses patients with COVID-19 who survive the virus and describes ineffective support due to lack of understanding and empathy regarding the long-COVID survivors experience.

Amid the COVID-19 pandemic, meaningful communication between family caregivers and residents of long-term care facilities is imperative.

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Hado E, Friss Feinberg L. J Aging Soc Policy. 2020;32:410-415.

These authors discuss the role of family caregivers during the COVID-19 pandemic and suggest avenues to support the relationship between families and residents of long-term care facilities, including strengthening communicating channels, activating family councils, and utilizing gerontological social work students.

Circumstances involved in unsupervised solid dose medication exposures among young children.

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Agarwal M, Lovegrove MC, Geller RJ, et al. J Pediatr. 2020;219.

Parents are advised to keep medications inaccessible to young children to avoid accidental ingestions. This study prospectively enrolled nearly 4,500 individuals calling poison control centers about unsupervised solid dose medication exposure in young children (ages 5 years and younger) to identify the types of containers from which young children accessed these medications. The majority of incidents (71.6%) involved children 2 years and younger. Incidents were equally divided among calls involving prescription-only medications, over-the-counter (OTC) projects requiring child-resistant packaging, and OTC projects not requiring such packaging. One-third of all incidents involved medication that had been removed from the original container; this was more likely in incidents involving prescription drugs compared to OTC drugs (adjusted odds ratio, 3.39; 95% CI, 2.87-4.00). These findings suggest that unsupervised medication exposures in young children are just as often the result of adults removing medications from original packaging as the result of improper use or failure of child-resistant packaging.

FDA alerts patients and health care professionals of EpiPen auto-injector errors related to device malfunctions and user administration.

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FDA alerts patients and health care professionals of EpiPen auto-injector errors related to device malfunctions and user administration. MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration. March 24, 2020.

Device related errors reduce the safety of medications. This announcement highlights concerns associated with the use of epinephrine auto-injectors. Recommendations to address the problem include patient review of instructions and practice with the device to ensure its effective use in emergent situations.

Their kids died on the psych ward. They were far from alone, a Times investigation found.

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Karlamangla S. Los Angeles Times. December 1, 2019.

Patient suicide is considered a sentinel event. This feature shares an examination of approximately 100 preventable deaths in the State of California over a decade. An examination of the case records identified breakdowns in care processes such as lack of training, low staffing and human error.

Sepsis Smart.

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Massachusetts Sepsis Consortium.

Delayed diagnosis of sepsis is a primary patient safety concern. This campaign raises awareness of the symptoms of sepsis to engage patients in timely diagnosis and safe treatment of the condition.

Unprotected: Broken promises in Georgia’s senior care industry.

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Schrade B, Teegardin C. Atlanta Journal-Constitution. Sept-October 2019.

Assisted living facilities have challenges that reduce the quality and safety of care. This news investigation examines how poor management, staffing shortages, and poor caregiver training were unchecked by systemic failures in correcting problems to protect residents.

Condition Help.

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Pittsburg, PA: UPMC Shadyside Hospital: 2019.

This brochure informs patients and their families about the Condition H helpline at University of Pittsburgh Medical Center (UPMC) Shadyside hospital, which can be used to call a rapid response team to immediately address concerns in a patient's condition. The helpline was developed in memory of Josie King.

Patient safety incidents in advance care planning for serious illness: a mixed-methods analysis

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Dinnen T, Williams H, Yardley S, et al. BMJ Support Palliat Care. 2019.

Advance care planning (ACP) allows patients to express and document their preferences about medical treatment; however, there are concerns about uptake and documentation due to human error. This study used patient safety incident reports in the UK to characterize and explore safety issues arising from ACP and to identify areas for improvement. Over a ten-year period, there were 70 reports of an ACP-related patient safety incident (due to incomplete documentation, inaccessible documentation or miscommunication, or ACP directives not being followed) which led to inappropriate treatment, transfer or admission. The importance of targeting the human factors of the ACP process to improve safety is discussed. The PSNet Human Factors Engineering primer expands on these concepts.

The role of personal health information management in promoting patient safety in the home: a qualitative analysis

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Demiris G, Lin S-Y, Turner AM. Stud Health Technol Inform . 2019;264:1159-1163.

Patient safety in the home has not been well defined and there have been few studies of this setting. This study examines the concept of patient safety in the home and identifies personal health information management tools to support and maximize patient safety in the home. The study findings demonstrate the physical, emotional, social and functional dimensions of patient safety in the home and ways for informatics tools to maximize safety aspects.

Patient Safety.

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Harrisburg, PA: Patient Safety Authority. ISSN 2641-4716.

The Pennsylvania Patient Safety Authority is a long-established source of patient safety data analysis and application-focused commentary. Their publishing output aims to generate improvements in their state as well as throughout health care. This open-access publication replaces the quarterly Pennsylvania Patient Safety Advisory newsletter.

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