The PSNet Collection

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.

Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue.

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WebM&M Case March 29, 2023

This case describes a 13-year-old girl who presented to several health care providers with typical symptoms, physical signs, and early laboratory findings suggestive of adrenal insufficiency (AI) yet the diagnosis was delayed for several months due to diagnostic biases. After she suffered a sudden cardiac arrest during a visit to her local emergency department and was airlifted to a tertiary care facility, she was found to be in adrenal crisis secondary to Addison’s disease.

Hospital-Acquired Diabetic Ketoacidosis.

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WebM&M Case February 1, 2023

This WebM&M highlights two cases of hospital-acquired diabetic ketoacidosis (DKA) in patients with type 1 diabetes. The commentary discusses the role of the inpatient glycemic team to assist with diabetes management, the importance of medication reconciliation in the emergency department (ED) for high-risk patients on insulin, and strategies to empower patients and caregivers to speak up about medication safety.

Weight-based Medication Errors in Children.

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Farnborough, UK: Healthcare Safety Investigation Branch; February 2022.

Weight-calculation errors can result in pediatric patient harm as they affect medication prescribing, dispensing, and administration accuracy. This report examines factors contributing to a computation mistake that resulted in a child receiving a 10-fold anticoagulant overdose over a 3-day period. Areas of focus for improvement include use of prescribing technology, and the double-check as an error barrier.

An initiative to reduce insulin-related adverse drug events in a children's hospital.

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Lawson SA, Hornung LN, Lawrence M, et al. Pediatrics. 2022;149:e2020004937.

Insulin is a high-risk medication and can contribute to adverse events in pediatric patients. This paper describes one children’s hospital’s experience implementing a new standardized medication administration process for insulin and the impact on insulin-related adverse drug events (ADEs). Findings indicate that implementation of a PRN (i.e., “as needed”) ordering process and clinician education decreased insulin-related ADEs and reduced the time between blood glucose checks and insulin administration.

Adverse glycemic events and critical emergencies.

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ISMP Medication Safety Alert! Acute care edition. December 2, 2021;(24)1-4.

Insulin is a high-alert medication that requires extra attention to safely manage blood sugar levels in chronic or acutely ill patients. This alert highlights look-alike/sound-alike packaging, delayed medication reconciliation, and dietary monitoring gaps as threats to safe insulin administration in emergencies. Recommendations for improvement are provided for both general in-hospital, and post-discharge care.

Outpatient insulin-related adverse events due to mix-up errors: findings from two national surveillance systems, United States, 2012-2017.

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Geller AI, Conrad AO, Weidle NJ, et al. Pharmacoepidemiol Drug Saf. 2021;30:573-581.

The Institute for Safe Medication Practices (ISMP) classifies insulin as a high-risk medication. This study examines insulin mix-up errors that resulted in emergency department visits or other serious adverse events. Most cases of medication mix-up involved rapid-acting insulin. Recommended prevention strategies include increased patient education and human factors engineering.

Inpatient Stroke Management in an Adolescent with Type 1 Diabetes and Home Insulin Pump

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WebM&M Case October 28, 2020

A 14-year-old girl with type 1 diabetes (T1D) was admitted to the hospital after two weeks of heavy menstrual bleeding as well as blurred vision, headache and left arm numbness. MRI revealed an acute right middle cerebral artery (MCA) infarct.

Insulin pumps have most reported problems in FDA database.

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Mohr H, Weiss M. Associated Press. November 27, 2018.

Usability issues, poor design, and lack of effective instruction hinder safe use of medical equipment. This news article reports on problems associated with ambulatory use of insulin pumps submitted to a Food and Drug Administration database.

Adolescent Diabetes: A Routine Visit?

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WebM&M Case February 1, 2010

An overweight teenaged girl came to the pediatrics clinic for routine follow-up of her type 2 diabetes, complaining of nonspecific, intermittent abdominal pain and worsening acne. The physician prescribed topical acne cream and increased her diabetes medications. The next day, an obstetrician notified the pediatrician that this patient had delivered a healthy infant via Caesarian section overnight.

Finding blunders in thyroid testing: experience in newborns.

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Zilka LJ, Lott JA, Baker LC, et al. J Clin Lab Anal. 2008;22:254-6.

Inconsistent and possibly erroneous results of thyroid tests for newborns occurred in 18 patients among 600,000 tested in this study. The authors recommend follow-up studies to determine the reproducibility of these results.

Designing decision support for insulin ordering in a computerized provider order entry system.

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Wright L, Feldott CC, Hargrove FR. Hosp Pharm. 2010;42.

The authors describe one hospital's effort to reduce pediatric insulin prescribing errors by including decision support in their computerized provider order entry system.

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