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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 129 Results

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; September 29, 2022.

Recalls of medications due to labeling errors are an established approach to minimize the potential for harm. This announcement highlights a labeling mistake with hypertension and antiplatelet medications that could result in dose omissions or bleeding risk.
Rockville, MD: US Department of Health and Human Services, Food and Drug Administration, Center for Drug Evaluation and Research; May 18, 2022.
This guidance outlines design elements that reduce errors associated with medication labels. Improvements suggested include tall-man lettering use, look-alike / sound alike avoidance and abbreviation minimization.

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.
Curated Libraries
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...

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.
US Food and Drug Administration. October 7, 2021.
Errors of commission during complex procedures can contribute to patient harm. Drawing from an analysis of medical device reports submitted to the Food and Drug Administration, this updated announcement seeks to raise awareness of common adverse events associated with surgical staplers and implantable staples. User-related problems include opening of the staple line, misapplied staples, and staple gun difficulties. Recommendations include ensuring availability of various staple sizes and avoiding use of staples on large blood vessels.

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.

Silver Spring, MD: US Department of Health and Human Services, Food and Drug Administration, Center for Devices and Radiological Health. May 20, 2021.

Magnetic resonance imaging (MRI) suites harbor unique hazards that can harm patients, should process missteps occur. This report shares assessment steps to assure that medical devices are labeled appropriately to support their safe use in the MRI environment and encourages organizational reporting of problems encountered when testing device use.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; May 4. 2021.

Anesthesia medications can be high risk should dosing errors occur. This company announcement reports a recall of two lots of anesthetics that have been mislabeled to mitigate the potential for patient harm due to misinformation.

Silver Spring, MD: Division of Industry and Consumer Education, US Food and Drug Administration; February 9. 2021.

Lack of access to ventilators during the COVID-19 crisis has necessitated care compromises to support multiple patients. This situation can reduce the effectiveness of monitoring patients on shared devices and introduce other challenges. This communication provides insights to enhance the safety of multiple-patient ventilator use.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 27, 2021.  

Labeling mistakes in the pharmaceutical production cycle can remain undetected until the affected medication reaches a patient. This alert reports a recall of a neuromuscular blocker for use in surgery due to it being mislabeled as a medication to increase blood pressure. 

Rockville, MD: US Department of Health and Human Services, Food and Drug Administration, Center for Drug Evaluation and Research; December 7, 2020. 

Nonprescription drugs are commonly associated with medication errors. This draft guidance seeks to provide a structure for industry to reduce instances of drug name confusion in nonprescription formulas of prescription medications. It describes the US Food and Drug Administration (FDA) vetting process for drug names to improve naming actions prior to submission to the agency. The timeline for submitting comments is early February 2021. 

Rockville, MD: US Department of Health and Human Services, Food and Drug Administration, Center for Drug Evaluation and Research; December 2020.

Look-alike and sound-alike names weaken the safety of medication use. This guidance provides a structure for industry to reduce instances of drug name similarities and describes the US Food and Drug Administration (FDA) vetting process for drug names to improve naming actions prior to submission to the agency.

FDA Safety Communication. MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; December 7, 2020.

Magnetic resonance imaging (MRI) requires patient preparation steps to protect against inadvertent harm. This announcement cautions patients and providers to assess masks being worn to protect against COVID-19 transmission for metal components that can result in patient burns during the exam. Recommendations for safety include enhanced screening to ensure masks are safe for the exam environment.