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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 71 Results

Noguchi Y. Health Shots and All Things Considered. National Public Radio. October 23, 2023.

Drug shortages, while often discussed as a system failure, demonstrate harm at an individual level. This story highlights the work of a patient activist who was inspired by the threat to her daughter’s care posed by a lack of chemotherapy availability, to provide needed medications during system disruptions to keep patients safe.
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.

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.

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.

Lovelace B, Jr, Kopf M. NBC. April 11, 2023.

Shortages of life-saving cancer drugs have been a problem for many years and were exacerbated by the COVID-19 pandemic. This news article reports that low profitability of manufacturing generic drugs contributes to this shortage. Until these cancer drugs are available, many patients will receive no treatment, or treatment that is less than ideal.

Whitaker B. CBS News. May 22, 2022.

Drug shortages represent a complex system level challenge in health care that can harm patients. This news segment details economic and production factors that affect the availability of generic medications. Clinicians and families were interviewed to share tactics for managing these situations to support patient safety despite shortages.
Lin MP, Vargas-Torres C, Shin-Kim J, et al. Am J Emerg Med. 2022;53:135-139.
Drug shortages can result in patient harm, such as dosing errors from a medication substitution. In this study, 28 of the 30 most frequently used medications in the emergency department experienced shortages between 2006 and 2019. The most common reasons for shortages were manufacturing delays and increased demand. The COVID-19 pandemic exacerbated pre-existing drug shortages.
Perspective on Safety March 30, 2021

In this PSNet Annual Perspective, we worked with co-authors Dr. Jacqueline C. Stocking, a quality improvement and critical care specialist, and Dr. Christian Sandrock, a patient safety professional and emerging infectious diseases specialist, to provide a look at news and research related to the impact of the COVID-19 pandemic on patient safety.

In this PSNet Annual Perspective, we worked with co-authors Dr. Jacqueline C. Stocking, a quality improvement and critical care specialist, and Dr. Christian Sandrock, a patient safety professional and emerging infectious diseases specialist, to provide a look at news and research related to the impact of the COVID-19 pandemic on patient safety.

Bookwalter CM. US Pharmacist. 2021;46(2):25-28. 

 

COVID-19 has increased uncertainties in sectors across health care. This article discusses a variety of supply-chain factors that impact medication availability. The author suggests roles for pharmacists in antibiotic stewardship and policy implementation to manage shortages safely.
Miller FA, Young SB, Dobrow M, et al. BMJ Qual Saf. 2020;30:331-335.
The COVID-19 pandemic has raised concerns about medical product shortages and demand surges, and the resulting effects on patient safety. This viewpoint discusses medical product supply chain vulnerabilities heightened by the COVID-19 pandemic. The authors summarize the evidence on supply chain resilience and medical product shortage, provide examples to illustrate key vulnerabilities, and discuss reactive and proactive solutions for medical product shortage.
Jazieh AR, Akbulut H, Curigliano G, et al. JCO Glob Oncol. 2020;6):1428-1438.
Patients with chronic health needs, including those with cancer, and their providers face numerous challenges during the COVID-19 pandemic. Survey results from 356 health care centers across 54 countries indicate that the impact of the COVID-19 pandemic on cancer care is widespread. Many centers reported challenges in delivering care, reduction in services, lack of personal protective equipment, staffing shortages, and limited access to medications. Respondents also reported potential patient harm due to interruptions in cancer-specific and non-cancer care.
Piatek OI, Ning JC-min, Touchette DR. Am J Health Syst Pharm. 2020;7:1778-1785.
Drug shortages are an ongoing threat to safe patient care. This commentary discusses the impact of COVID-19 on medication supply and demand, and the resulting drug shortages. The authors provide several recommendations for reducing future drug shortages in times of crises, including increasing stockpiles and creating a critical drug list with potential substitutes.
Girion L, Levine D, Respaut R. Reuters. 2020;June 9.
The COVID-19 pandemic has disrupted the supply of protective equipment, medical devices and medications. This article discusses how economics contribute to drug shortages and highlights the specific impact on access to the opioids essential for providing safe care for hospitalized patients with COVID-19.

Institute for Safe Medication Practices and US Food and Drug Administration Division of Drug Information. June 23, 2020.

The COVID-19 pandemic response is creating a need for care delivery adjustments that include changes in pharmacy and medication practices. This webinar discussed process alterations that have the potential to impact safe medication administration and provide context for the changes to help ensure they are effectively implemented.
Alexander GC, Qato DM. JAMA. 2020;324:31-32.
The COVID-19 pandemic has raised concerns about the pharmaceutical supply chain, from overseas manufacturing to medication distribution within the United States. This commentary presents several emergency response and preparedness measures for policymakers, pharmaceutical distributors and pharmacies to prepare for drug shortages and demand surges. Suggested measures include developing an “essential medicines” strategy, using allocation strategies that prevent stockpiling and drug shortages and expanding capacity for mail-order and home delivery.