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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 672 Results
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.

Banks MA. Specialty Pharmacy Continuum. September 15, 2023.

Radiofrequency identification (RFID) devices are being used to improve processes in the operating room and prevent errors. This article examines the use of RFID tracking to build reliability into operating room anesthesia medication refiling process. The experience at one hospital found that the RFID process reduced errors, while increasing the task completion time.
Kramer JS, Hayley Burgess L, Warren C, et al. J Patient Saf Risk Manag. 2023;Epub Aug 27.
Obtaining a best possible medication history (BPM) is an important component of successful medication reconciliation programs. This study compared the impact of a pharmacy-led medication reconciliation program including BPMH on adverse drug events (ADEs) and complications among high-risk, complex patients across 16 hospitals. In the six months following implementation, 80,000 reconciliations were completed and nearly 40% required additional medication follow-up and/or clarification. Researchers identified a statistically significant decrease in both ADEs and complications after implementation.
Christensen SM, Andrews SR, Fox ER. Am J Health Syst Pharm. 2023;80 :S119-S122.
To maximize safety benefits of smart infusion pumps, drug libraries between the pump, electronic health record (EHR) and pharmacy must be standardized. This article describes the proactive standardization between drug libraries for continuous infusions, including medication names, concentrations, and pump rates. 82 updates were required across the three libraries.
Ojeda IM, Sánchez-Cuervo M, Candela-Toha Á, et al. Crit Care Nurs. 2023;43:30-38.
High-alert medications can cause serious patient harm if administered incorrectly. This article describes a quality improvement project to reduce medication errors involving high-alert sedative and analgesic medications in the intensive care unit (ICU) through use of protocolized and centralized smart intravenous infusion pump technology. Use of the protocolized software led to the interception of nearly 400 infusion-related programming errors.
Patient Safety Primer August 30, 2023
Anyone can find it challenging to understand medical terms, and millions of Americans have trouble understanding and acting upon health information. The mismatch between individuals' health literacy skills and the complexity of health information and health care tasks involved in managing health has implications on patient safety.

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.
Melnyk BM, Hsieh AP, Tan A, et al. J Occup Environ Med. 2023;65:699-705.
Many healthcare professionals experienced adverse emotional and psychological outcomes during the COVID-19 pandemic. This survey of 665 health system pharmacists found that pharmacists working in settings with higher levels of workplace wellness support were less likely to experience depression, anxiety, or burnout, and report higher levels of professional quality of life during the COVID-19 pandemic.

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.
Dunbar EG, Massey AC, Lee YL, et al. Am Surg. 2023;89:3272-3274.
Medication reconciliation is an important care process anytime a patient transitions from one care setting to another, including emergency department to hospital admission. This study sought to determine the incidence of completed medication reconciliation for admitted trauma patients and the number of identified discrepancies. Of the 89 patients included in the study, more than a quarter did not receive an admission medication reconciliation (AMR), and of those with an AMR, 48% had at least one unintended discrepancy, indicating the importance of completing medication reconciliation for all admitted trauma patients.
Barlow M, Morse KJ, Watson B, et al. Adv Simul (Lond). 2023;8:17.
Patient safety is improved when all members of the care team feel empowered to speak up about concerns. Equally important is the way the receiver understands and responds to the concern. Through an interprofessional simulation, this study assessed barriers and enablers of receiving a safety concern expressed by a junior nurse, either abruptly or politely and respectfully. Barriers and enablers to receiving the message were about equal no matter the way the concern was expressed, suggesting trainings that focus on speaking up should also focus on receiving those messages.

ISMP Medication Safety Alert! Acute care edition. July 13, 2023;(4):1-3;July 27, 2023;(5):1-5.

Risk Evaluation and Mitigation Strategy (REMS) programs help to ensure the safe use of distinct medications through communication, patient information, and implementation support. Part I of this article series examines systemic barriers to the deployment of REMS as a strategy to decrease potential for drug-related harm and medication error. Part II looks at the processes that one health system used to implement REMS.
Walsh DJ, Sahm LJ, O'Driscoll M, et al. J Geriatr Oncol. 2023;14:101540.
Older adults with cancer are typically prescribed multiple medications (i.e., polypharmacy) and are therefore at risk of adverse drug events (ADE). In this study, the medical records of older adults (those at least 70 years old) receiving cancer care who had an unplanned hospital admission were reviewed to determine if it was potentially related to an ADE. Of the hospitalized patients, more than half were potentially due to ADE at three and six months after the initial oncology visit. Including a clinical pharmacist may help reduce ADEs and hospitalizations.
Wang Y, Eldridge N, Metersky ML, et al. Circ Cardiovasc Qual Outcomes. 2023;16:e009573.
Unplanned hospital readmission and 30-day all-cause mortality rates are indicators of hospital safety. This study analyzed the association of these two indicators with in-hospital adverse events (AE) for patients admitted with heart failure. Results suggest patients with heart failure admitted to hospitals with high rates of 30-day all-cause mortality and readmission are at increased risk for in-hospital AE. The authors describe several possible explanations for these findings.
Estock JL, Codario RA, Keddem S, et al. Diabetes Technol Ther. 2023;25:343-355.
Insulin pump malfunctions are a known contributor to adverse events. This study used six months of adverse events reported to the Food and Drug Administration's (FDA) Manufacturer and User Facility Device Experience (MAUDE) database to identify root causes and consequences of errors associated with insulin pump malfunctions. Hyper- and hypoglycemia were the most common clinical consequences of the malfunction; only half of the reports identified a potential root cause.
Joshi RN, Kalaminsky S, Feemster A-A, et al. Jt Comm J Qual Patient Saf. 2023;Epub Jun 24.
Technology, such as barcode scanning, is a recognized method for improving medication safety, but poor design may lead to alert fatigue. This article describes a quality improvement project to reduce barcode-assisted medication preparation alerts in the hospital's pharmacies. More than 40% of alerts were identified as "barcode not recognized," such as packages containing more than one barcode. Problems associated with the highest volume of alerts were resolved with staff education, workflow changes, and changes.
Jarrett P, Keogh S, Roberts JA, et al. Intensive Crit Care Nurs. 2023;77:103403.
As with all medications, delays in or underdosing of antimicrobials can result in unnecessarily long hospital stays. This study found that discarded antibiotic vials in the intensive care unit (ICU) contained residual drug remaining in the vial (median 3.7% error). This finding suggests patients may not be receiving the full prescribed dose.
Pradeda AM, Pérez MSA, Oliveira CF, et al. Farm Hosp. 2023;47:121-126.
Medication reconciliation is used when a patient moves from one level or location of care to another, to ensure they are receiving the appropriate medications. This retrospective study reviewed completed medication reconciliations of adult patients transferring from the intensive care unit to the ward. Nearly one in five had an error requiring physician changes to the order. Of those errors, 19% were high-alert medications, most notably low-molecular-weight heparin.
Zahl-Holmstad B, Garcia BH, Johnsgård T, et al. BMJ Open Qual. 2023;12:e002239.
Designated emergency department (ED) pharmacists are increasingly used to improve the quality of medication administration in the ED. This qualitative study explored patient perceptions of medication safety before and during an ED pharmacist-led intervention (including medication reconciliation and medication review) in collaboration with ED physicians. Participants underscored the importance of trust and responsibility but noted that it was not important who carried out these medication-related tasks, but rather that the participant received the help they needed.
Mahomedradja RF, Schinkel M, Sigaloff KCE, et al. Br J Clin Pharmacol. 2023;89:1724-1735.
Despite extensive research and interventions, medication prescribing errors in hospital continue to occur. This review sought to identify prescribing errors and factors that facilitate or prevent prescribing errors. Prescribing errors were categorized as prescriber-, prescription-, technology-, or organization-related, or unclassified. Most errors were organization-related. The authors recommend examining facilitators and barriers to prescribing safety prior to implementing new interventions.