Skip to main content

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

Search Tips
Save
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Search By Author(s)
Additional Filters
Approach to Improving Safety
Safety Target
Displaying 1 - 20 of 1077 Results
Loo VC, Kim S, Johnson LM, et al. J Patient Saf. 2023;Epub Aug 25.
Ensuring the safety of clinical trial participants is paramount to successful, meaningful clinical research. In this study, researchers examined 585 clinical trial documents and found that 17% included potential patient safety interventions (e.g., resolving medication dosing discrepancies). The authors suggest that clinical specialists’ review of study protocol documents could enhance patient safety during clinical trial conduct.
Plymouth Meeting, PA: Institute for Safe Medication Practices; 2023.
Experience from the sharp end helps to inform safety improvement initiatives. The results from this field survey will inform the revision of a high-alert medication list used to raise awareness about certain drugs that have heightened potential to cause patient harm if used incorrectly. The deadline for submitting comments is October 20, 2023.
Lockery JE, Collyer TA, Woods RL, et al. J Am Geriatr Soc. 2023;71:2495-2505.
Potentially inappropriate medications (PIM) are a known contributor to patient harm in older adults. In contrast to most studies of PIM in patients with comorbid conditions or residing in hospitals or nursing homes, this study evaluated the impact of PIM use in community-dwelling older adults without significant disability. Participants with at least one PIM were at increased risk of physical disability and hospitalization over the study period (8 years) than those not taking any PIM. However, both groups had similar rates of death.
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.
Baimas-George MR, Ross SW, Yang H, et al. Ann Surg. 2023;278:e614-e619.
Hospital-acquired venous thromboembolism (VTE) remains a significant source of preventable patient harm. This study of 4,252 high-risk general surgery patients found that only one-third received care in compliance with VTE prophylaxis guidelines. Patients receiving guideline-compliant care experienced shorter lengths of stay (LOS), fewer blood transfusions, and decreased odds of having a VTE, emphasizing the importance of initiating VTE chemoprophylaxis in high-risk general surgery patients.
WebM&M Case August 30, 2023

A 31-year-old pregnant patient with type 1 diabetes on an insulin pump was hospitalized for euglycemic diabetic ketoacidosis (DKA). She was treated for dehydration and vomiting, but not aggressively enough, and her metabolic acidosis worsened over several days. The primary team hesitated to prescribe medications safe in pregnancy and delayed reaching out to the Maternal Fetal Medicine (MFM) consultant, who made recommendations but did not ensure that the primary team received and understood the information.

Kinsella SM, Boaden B, El‐Ghazali S, et al. Anaesthesia. 2023;Epub Jul 26.
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.
Inadvertent overprescribing and polypharmacy in the 65-year old or older patient population is a contributor to patient harm. The Beers criteria serve as standard guidance for clinicians to prevent the potential for Inappropriate medication prescribing. This guideline updates existing recommendations and simplified the listing by removing rarely used medications in the geriatric population.
Hogerwaard M, Stolk M, Dijk L van, et al. BMJ Open Qual. 2023;12:e002023.
Barcode medication administration (BCMA) technology is a useful tool to reduce medication administration errors (MAE) in the operating room. This study used a pre-post design to estimate the rate of MAE before and after BCMA implementation on infusion pumps. MAE were significantly reduced and up to 90% of errors were considered preventable, if the staff had utilized BCMA. Reasons for not using BCMA included unreadable barcodes, lack of time, and resistance to new processes.
Powis M, Dara C, Macedo A, et al. BMJ Open Quality. 2023;12:e002211.
Medication reconciliation can help providers identify potential safety issues during medication administration. Based on interviews with stakeholders, this study examined medication reconciliation practices across Canadian cancer centers. Although a high proportion of the centers had a process for collecting best possible medication history (BPMH, 81%), implementation of a complete medication reconciliation process was uncommon. Stakeholders identified several barriers to implementation, including lack of resources and a lack of electronic health record interoperability across institutions, systems, and community pharmacies.

Burton S. New York Times and Serial Productions. June 30-July 27, 2023.

Unnoticed drug diversion can result in harm to patients, clinicians, and organizations. This series describes how diversion contributed to unnecessary pain in fertility clinic patients. The problem was compounded by a lack of attention to women voicing their concerns about procedural pain.
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.
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.
Fanikos J, Tawfik Y, Almheiri D, et al. Am J Med. 2023;136:927-936.
Anticoagulants are high-risk medications in both outpatient and inpatient settings. This study compared two time periods, both before and after implementation of anticoagulant safety programs, to assess changes in type, severity, root cause, and outcomes of adverse events in hospitalized patients. Despite numerous changes in procedures and technology, adverse events increased in the post-implementation period.
Horsham, PA; Institute for Safe Medication Practices: July 2023.
Drawing on information gathered from the ISMP Medication Errors Reporting Program, this fact sheet provides a comprehensive list of commonly confused medication names, including look-alike and sound-alike name pairs. Drug name confusion can easily lead to medication errors, and the ISMP has recommended interventions such as the use of tall man lettering in order to prevent such errors. An error due to sound-alike medications is discussed in this AHRQ WebM&M commentary.
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.
Mohamed MR, Mohile SG, Juba KM, et al. Cancer. 2023;129:1096-1104.
Polypharmacy in older adults increases the risk of potentially inappropriate medications (PIM) and potential drug-drug interactions (PDI). This secondary analysis of a national study of older adults with advanced cancer sought to identify associations between polypharmacy (eight or more medications), PIMs, and PDIs with adverse cancer treatment outcomes. Polypharmacy and PDIs were associated with increased risk of adverse treatment outcomes, but PIMs were not.
Rowily AA, Jalal Z, Paudyal V. Expert Opin Drug Saf. 2023;Epub Jun 14.
Direct oral anticoagulant (DOAC) dosing is complex and can lead to medication errors. This analysis of 15,730 incident reports involving DOACs reported in the United Kingdom between 2017 and 2019 found that the majority (87.6%) were due to active failures and 2.2% resulted in moderate/severe harm or death. This PSNet WebM&M commentary discusses approaches to improving safety when prescribing DOACs.

Anesthesia Patient Safety Foundation. 2020-2023.

Work to improve anesthesia is longstanding. This free podcast series from the Anesthesia Patient Safety Foundation is updated regularly to cover a range of topics as they affect anesthetic safety including work environment, artificial intelligence, and look-alike, sound-alike medications.
Riester MR, Goyal P, Steinman MA, et al. J Gen Intern Med. 2023;38:1563-1566.
Potentially inappropriate medication (PIM) prescribing in older adults is common and can lead to medication-related harm. This retrospective study of Medicare beneficiaries estimated that the prevalence of PIM use was 77% among long-stay nursing home residents (defined as >101 consecutive days in a nursing home). The most common PIMs were benzodiazepines, antipsychotics, and insulin.