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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 826 Results
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.

Armstrong Institute for Patient Safety and Quality.
The comprehensive unit-based safety program (CUSP) approach emphasizes improving safety culture through a continuous process of reporting and learning from errors, improving teamwork, and engaging staff at all levels in safety efforts. Available on demand and live, this session covers how to utilize CUSP, including understanding and addressing challenges to implementation. The next virtual session will be held April 18-19, 2023.
Cresham Fox S, Taylor N, Marufu TC, et al. Intensive Crit Care Nurs. 2022;Epub Dec 3.
While many hospitals have rapid response teams (RRT) which can be activated by clinicians, only a few hospitals have also implemented programs which allow patients and families to activate RRT. This review identified 6 articles (5 interventions) with family-activated RRT in pediatric hospitals. The authors of the review conclude that family-activated RRT is a key component to family engagement and enhancing patient safety. Only one intervention was also available in a non-English language, which should be considered in future interventions.
Rodgers S, Taylor AC, Roberts SA, et al. PLoS Med. 2022;19:e1004133.
Previous research found that a pharmacist-led information technology intervention (PINCER) reduced dangerous prescribing (i.e., medication monitoring and drug-disease errors) among a subset of primary care practices in the United Kingdom (UK). This longitudinal analysis examined the impact of the PINCER intervention after implementation across a large proportion of general practices in one region in the UK. Researchers found the PINCER intervention decreased dangerous prescribing by 17% and 15% at 6-month and 12-month follow-ups, particularly among dangerous prescribing related to gastrointestinal bleeding.
Heesen M, Steuer C, Wiedemeier P, et al. J Patient Saf. 2022;18:e1226-e1230.
Anesthesia medications prepared in the operating room are vulnerable to errors at all stages of medication administration, including preparation and dilution. In this study, anesthesiologists were asked to prepare the mixture of three drugs used for spinal anesthesia for cesarean section. Results show deviation from the expected concentration and variability between providers. The authors recommend all medications be prepared in the hospital pharmacy or purchased pre-mixed from the manufacturer to prevent these errors. 
Pratt BR, Dunford BB, Vogus TJ, et al. Health Care Manage Rev. 2022;48:14-22.
Organizational pressures sometimes lead to redeployment or task reallocation such as shifting infusion tasks from specialty nurse teams to generalist nurses. This survey of nurses in the United States found that infusion task reallocation led to increased job demands and reduced resources, thereby contributing to lower perceived organizational safety.
Balshi AN, Al-Odat MA, Alharthy AM, et al. PLoS ONE. 2022;17:e0277992.
Many hospitals have implemented rapid response teams (RRT) that are activated when a patient starts exhibiting prespecified criteria to prevent adverse outcomes. This before and after study compared nurse-activated RRT and automated activation. Non-invasive bedside sensors monitored patients’ vital signs and automatically sent alerts to the RRT based on prespecified clinical signs. Compared to the before period, there were lower rates of CPR, higher rates of successful CPR, shorter lengths of stay, and lower hospital mortality.
Sallevelt BTGM, Egberts TCG, Huibers CJA, et al. Drug Saf. 2022;45:1501-1516.
Adverse events, such as medication errors, are a major cause of hospital admissions. This retrospective study of a subset of OPERAM intervention patients who were readmitted with a potentially preventable drug-related admission (DRA) examined whether use of STOPP/START criteria during in-hospital medication review can identify medication errors prior to a potentially preventable DRA. Researchers found that medication errors identified at readmission could not be addressed by prior in-hospital medication reviews because the medication error occurred after the in-hospital review or because recommended medication regimen changes were not provided or not implemented.

ISMP Medication Safety Alert! Acute care edition. November 17, 2022;27(23).

Enteral feeding tube medication delivery presents safety challenges that can cause harm. This article highlights problems with feed tube medication administration. It shares improvement recommendations that include best practice adherence, standardization, monitoring, and patient engagement.
Johansen JS, Halvorsen KH, Svendsen K, et al. BMC Health Serv Res. 2022;22:1290.
Reducing unplanned hospital readmissions is a priority patient safety focus, and numerous interventions with hospital pharmacists have been developed. In this study, hospitalized adults aged 70 years and older were randomized to receive standard care or the IMMENSE intervention. The IMprove MEdicatioN Safety in the Elderly (IMMENSE) intervention is based on the integrated medicine management (IMM) model and consists of five steps, including medication reconciliation, patient counseling, and communication with the patient’s primary care provider. There was no significant difference in emergency department visits or readmissions between control and intervention within 12 months of the index hospital visit.
Iturgoyen Fuentes DP, Meneses Mangas C, Cuervas Mons Vendrell M. Eur J Hosp Pharm. 2022;Epub Sep 30.
Medication reconciliation at hospital admission has reduced medication errors, but less is known about the pediatric population, particularly which patients may benefit most from reconciliation. This retrospective study of pediatric patients who experienced at least one medication reconciliation error found children older than 5 years, taking 4 or more medications, or with neurological or onco-hematological conditions were at increased risk of errors. Prioritization of these populations may improve the effectiveness of medication reconciliation.
WebM&M Case November 16, 2022

A 61-year-old women with a mechanical aortic valve on chronic warfarin therapy was referred to the emergency department (ED) for urgent computed tomography (CT) imaging of the right leg to rule out an arterial clot. CT imaging revealed two arterial thromboses the right lower extremity and an echocardiogram revealed a thrombus near the prosthetic heart valve. The attending physician ordered discontinuation of warfarin and initiation of a heparin drip.

Ibrahim M, Szeto WY, Gutsche J, et al. Ann Thorac Surg. 2022;114:626-635.
Reports of poor care in the media or public reporting systems can serve as an impetus to overhauling hospitals or hospital units. After several unexpected deaths and a drop in several rating systems, this cardiac surgery department launched a comprehensive quality improvement review. This paper describes the major changes made in the department, including role clarity and minimizing variation in 24/7 staffing.
Laing L, Salema N-E, Jeffries M, et al. PLoS ONE. 2022;17:e0275633.
Previous research found that the pharmacist-led IT-based intervention to reduce clinically important medication errors (PINCER) can reduce prescription and medication monitoring errors. This qualitative study explored patients’ perceived acceptability of the PINCER intervention in primary care. Overall perceptions were positive, but participants noted that PINCER acceptability can be improved through enhanced patient-pharmacist relationships, consistent delivery of PINCER-related care, and synchronization of medication reviews with prescription renewals.
Beerlage-Davids CJ, Ponjee GHM, Vanhommerig JW, et al. Int J Clin Pharm. 2022;44:1434-1441.
Older adults taking multiple medications are at increased risk for adverse drug events following hospital discharge. In this study, patients were contacted two weeks after hospital discharge to evaluate adverse events, adverse drug events, and health-related quality of life (HRQoL). There was a weak but significant correlation between patient-reported adverse events and HRQoL, but not patient-reported adverse drug events.  
Punj E, Collins A, Agravedi N, et al. Pharmacol Res Perspect. 2022;10:e01007.
Pharmacists play an important role in preventing medication errors. This systematic review identified 17 studies showing that pharmacy teams working in acute or emergency medicine departments can reduce medication errors through medication reconciliation.
Sacarny A, Safran E, Steffel M, et al. JAMA Health Forum. 2022;3:e223378.
Concurrent prescribing of opioids and benzodiazepines can put patients at increased risk of overdose. This randomized study found that pharmacist email alerts to clinicians caring for patients recently co-prescribed opioids and benzodiazepines did not reduce concurrent prescribing of these medications.

ISMP Medication Safety Alert! Acute care edition. October 6, 2022;27(20):1-5.

Patient resuscitation is a complex, distinct, team activity that can be prone to error. Pharmacists involved in codes reported concerns including errors with high-alert medications and communication gaps. Improvement recommendations focused on preparation for, actions during and post code phrases which included standardizing the practice of including pharmacists in codes, simulation, and regular debriefing.
Girotra S, Jones PG, Peberdy MA, et al. Circ Cardiovasc Qual Outcomes. 2022;15:e008901.
Rapid response teams (RRTs) have been implemented at hospitals worldwide, despite mixed results in their effectiveness. The aim of this study was to compare expected mortality rates with mortality rates following RRT implementation, adjusted for hospital case mix. Of 56 hospitals that participated in this project and had complete data, only four showed lower-than-expected mortality rates and two showed higher-than-expected mortality, suggesting RRT may not reduce mortality rates as much as earlier studies have reported.