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.

Search All Content

Clear all filter(s)

Displaying 1 - 20 of 246 Results

California pharmacies are making millions of mistakes. They’re fighting to keep that secret.

Save to Library

Peterson M. Los Angeles Times. September 5, 2023.

Safe practice in community pharmacy is challenged by production pressure, workforce shortages, and multitasking. This story examined the mistakes made at major retail pharmacy chains in California. It provides examples perpetrated across the industry to target universal areas of needed improvement and potential strategies to address them.

Video review of simulated pediatric cardiac arrest to identify errors/latent safety threats: a mixed methods study.

Save to Library

Garcia-Jorda D, Nikitovic D, Gilfoyle E. Simul Healthc. 2023;18:232-239.

Simulation trainings are widely used to identify safety threats and improve processes. By analyzing video recordings of pediatric cardiac arrest simulations, researchers were able to identify 5 main areas of errors: clinical, planning and execution, communication, distraction, and knowledge/training. Investigating the root causes of these errors can result in improved trainings and, thus, improved patient outcomes.

Sentinel Event Alert 67: Preserving Patient Safety After a Cyberattack.

Save to Library

Jt Comm J Qual Patient Saf. 2023;Epub Aug 15.

Cyberattacks and technology disruptions are increasing as a threat to patient safety. This alert identifies risks linked to cyberattacks. The authors discuss how organizations might be proactive in order to prevent the potential for data breaches and reduce their impact on care delivery and processes should cyberattacks occur.

Handling injectable medications in anaesthesia: Guidelines from the Association of Anaesthetists.

Save to Library

Kinsella SM, Boaden B, El‐Ghazali S, et al. Anaesthesia. 2023;78:1285-1294.

Anesthesia provision is a high-risk practice. This guidance provides practical steps to ensure perioperative medication delivery is as safe as possible. This material recommends approaches for both clinicians and organizations to enable collaborative safety efforts in anesthesia, including prefilled syringes, standardization, and adherence to safe labeling practices.

Incivility in healthcare: the impact of poor communication.

Save to Library

Guppy JH, Widlund H, Munro R, et al. BMJ Lead. 2023;Epub Jul 7.

Incivility hinders clinical performance, increases errors, and negatively impacts safety culture. This review examines recent literature on the effects of incivility in healthcare and strategies to address it. The article proposes ways to implement those strategies, with an emphasis on the UK National Health Service. The authors conclude that tackling incivility begins with highlighting the issue organizationally, regionally, and nationally; ensuring robust reporting and recognition strategies; and, devising mechanisms to confront incivility.

Meta-analysis of medication administration errors in African hospitals.

Save to Library

Alemu W, Cimiotti JP. J Healthc Qual. 2023;45:233-241.

Medication administration is a complex process and prone to errors. This review was conducted to identify predictors and incidence of medication administration errors (MAE) in African hospitals. Most predictors were at the system level (e.g., work environment, interruptions), followed by patient and professional/provider factors. As the number of included studies was low (13 studies) and most came from one nation, additional studies are needed.

A data-driven approach to evaluate barcode-assisted medication preparation alerts at a large academic medical center.

Save to Library

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.

Exploring everyday work as a dynamic non-event and adaptations to manage safety in intraoperative anaesthesia care: an interview study.

Save to Library

Olin K, Klinga C, Ekstedt M, et al. BMC Health Serv Res. 2023;23:651.

The operating room is a high-risk environment involving complex tasks. This study used cognitive task analysis (CTA) to explore how anesthesia nurses and anesthesiologists manage complex everyday situations during intraoperative care processes. Findings underscore the importance of available resources, team composition, and non-technical skills (NTS) for managing complex daily work and promoting patient safety.

Content analysis of nurses' reflections on medication errors in a regional hospital.

Save to Library

Issacs AN, Raymond A, Kent B. Contemp Nurse. 2023;59:202-213.

Despite widespread improvement efforts, medication administration errors (MAE) remain a patient safety problem. In this study, nurses at one Australian hospital provided a reflection as to why they believed an MAE occurred and these reflections were subsequently analyzed using a human factors framework. Individual characteristics, nature of the work, and physical environment factors were identified as contributing to MAE and represent areas for improvement.

Assessing the impact of a new pediatric healthcare facility on medication administration: a human factors approach.

Save to Library

Godin MR, Nasr AS. J Nurs Adm. 2023;53:331-336.

Hospital design has been associated with patient safety incidents. This study compared rates of medication administration errors in the pediatric unit of a new evidence-based design (EBD) hospital with rates at the older facility prior to moving to the EBD hospital. Despite implementing EBD, rates of distractions were lower at the older facility; “interruption by physician” was the only distraction type to improve in the new EBD hospital.

Overlapping surgery in arthroplasty - a systematic review and meta-analysis.

Save to Library

Kim RG, An VVG, Lee SLK, et al. Orthop Traumatol Surg Res. 2023;109:103299.

Overlapping surgery, where “critical” portions of surgery are performed sequentially in separate operating rooms, is used to increase efficiency and number of procedures performed each day. This systematic review and meta-analysis was performed to determine differences in risk of complications between overlapping surgery (OS) and non-overlapping surgery (NOS) in total hip and total knee arthroplasty. Consistent with prior studies and reviews, there were no significant differences in adverse events or complications between OS and NOS. The authors stress that informed consent and patient education prior to OS is critically important.

Improving Diagnostic Safety and Quality

Save to Library

Perspective on Safety April 26, 2023

Throughout 2022, AHRQ PSNet has shared research that elucidates the complex nature of misdiagnosis and diagnostic safety. This Year in Review explores recent work in diagnostic safety and ways that greater safety may be promoted using tools developed to improve diagnostic practices.

Distractions in the operating room: a survey of the healthcare team.

Save to Library

Nasri B-N, Mitchell JD, Jackson C, et al. Surg Endosc. 2023;37:2316-2325.

Distractions in the operating room can contribute to errors. Based on survey responses from 160 healthcare workers, this study examined perceived distractions in the operating room. All participants ranked auditory distractions as the most distracting and visual distractions as the least distracting, but the top five distractors fell into the equipment and environmental categories – (excessive heat/cold, team member unavailability, poor ergonomics, equipment unavailability, and competitive demand for equipment). Phone calls/pagers/beepers were also cited as a common distractor.

Managing interruptions to improve diagnostic decision-making: strategies and recommended research agenda.

Save to Library

Sloane JF, Donkin C, Newell BR, et al. J Gen Intern Med. 2023;38:1526-1531.

Interruptions during diagnostic decision-making and clinical tasks can adversely impact patient care. This article reviews empirically-tested strategies from healthcare and cognitive psychology that can inform future research on mitigating the effects of interruptions during diagnostic decision-making. The authors highlight strategies to minimize the negative impacts of interruptions and strategies to prevent distractions altogether; in addition, they propose research priorities within the field of diagnostic safety.

Distraction of the Anesthesiologist and Lack of Resuscitation Drugs Resulting in Delayed Treatment of Laryngospasm.

Save to Library

WebM&M Case March 15, 2023

A 48-year-old woman was placed under general anesthesia with a laryngeal mask. The anesthesiologist was distracted briefly to sign for opioid drugs in a register, and during this time, the end-tidal carbon dioxide alarm sounded. Attempts to manually ventilate the patient were unsuccessful. The anesthesiologist asked for suxamethonium (succinylcholine) but the drug refrigerator was broken and the medication had to be retrieved from another room.

Controlled substance drug diversion by healthcare workers as a threat to patient safety.

Save to Library

ISMP Medication Safety Alert! Acute care edition. February 23, 2023;28(4):1-4; March 9, 2023:28(5):1-4.

Drug diversion can reduce patient safety and should be addressed at a system level to reduce its occurrence and impact. Part I of this two-part series examines ways in which drug diversion can affect care teams, and outlines what to watch for to flag its occurrence at the clinician, record keeping, and medication inventory levels. Part II shares tactics to minimize controlled substance diversion, and track, document and take action when it does occur.

On Patient Safety.

Save to Library

Järvinen TLN, Rickert J, Lee MJ, et al. Clin Orthop Relat Res. 2013-2023.

This quarterly commentary explores a wide range of subjects associated with patient safety, such as the impact of disruptive behavior on teams, the value of apologies, and safety challenges due to COVID-19. Older materials are available online for free.

Work environment and operational failures associated with nurse outcomes, patient safety, and patient satisfaction.

Save to Library

Riman KA, Harrison JM, Sloane DM, et al. Nurs Res. 2023;72:20-29.

Operational failures – breakdowns in care processes, such as distractions or situational constraints – can impact healthcare delivery. This cross-sectional analysis using population-based survey data from 11,709 nurses examined the relationship between operational failures, patient satisfaction, nurse-reported quality and safety, and nurse job outcomes. Findings indicate that operational failures negatively impact patient satisfaction, quality and safety, and contribute to poor nurse job outcomes, such as burnout.

Prevalence, causes and severity of medication administration errors in the neonatal intensive care unit: a systematic review and meta-analysis.

Save to Library

Henry Basil J, Premakumar CM, Mhd Ali A, et al. Drug Saf. 2022;45:1457-1476.

Medication administration errors (MAEs) are thought to be common in neonatal intensive care units (NICUs). This systematic review estimated that the pooled prevalence of MAEs among patients in NICU settings ranged from 59% to 65%. The review highlights both active failures (e.g., similar drug packaging or names) and latent failures (e.g., noisy environments, inaccurate verbal or written orders) contributing to MAEs.

Health system redesign of cardiac monitoring oversight to optimize alarm management, safety, and staff engagement.

Save to Library

Engel JR, Lindsay M, O'Brien S, et al. J Nurs Adm. 2022;52:511-518.

Alert fatigue occurs when healthcare workers become desensitized to alarms over time, especially when alarms tend to be clinically nonsignificant, and therefore, ignored or not responded to. This study reports on one health system’s redesign of cardiac monitoring structure to reduce alert fatigue. Through a four-phase quality improvement project, three hospitals were able to decrease alarms by 74-95% and sustained the results for 12 months.

The PSNet Collection: All Content

Search All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

The PSNet Collection: All Content

Search All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site