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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Curated Libraries

Medication/Drug Errors

January 14, 2022

The medication-use process is highly complex with many steps and risk points for error, and those errors are a key target for improving safety. This Library reflects a curated selection of PSNet content focused on medication and drug errors. Included resources explore understanding harms from preventable medication use, medication safety...

Patient Safety Events and the Role of Patient Safety Organizations During the COVID-19 Pandemic

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Perspective on Safety January 12, 2022

This piece discusses patient safety challenges that arose as a result of the unique care circumstances surrounding the COVID-19 pandemic, particularly at the height of the pandemic in 2020.

Prevalence, contributory factors and severity of medication errors associated with direct-acting oral anticoagulants in adult patients: a systematic review and meta-analysis.

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Al Rowily A, Jalal Z, Price MJ, et al. Eur J Clin Pharmacol. 2022;78:623-645.

Although direct acting oral anticoagulants (DAOCs) are generally considered safer than older anticoagulants, they are still high-risk medications. This review found that between 5.3% and 37.3% of patients experienced either a prescription, administration, or dosing error. Prescribing errors constituted the majority of error types, and common causes were active failures, including wrong drug or wrong dose.

Where trust flourishes: perceptions of clinicians who trust their organizations and are trusted by their patients.

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Linzer M, Neprash HT, Brown RL, et al. Ann Fam Med. 2021;19:521-526.

Using data from the Healthy Work Place trial, this study explored characteristics associated with high clinician and patient trust. Findings suggest that trust is higher when clinicians perceived their organizational cultures as emphasizing quality, communication and information, cohesiveness, and value alignment between clinicians and leaders.

Program access, depressive symptoms, and medical errors among resident physicians with disability.

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Meeks LM, Pereira-Lima K, Frank E, et al. JAMA Netw Open. 2021;4:e2141511.

This survey estimates the prevalence of disability among medical residents to be 7.5%. Findings suggest an association between lack of accessibility through accommodations and increased risk for depression and self-reported medical errors during training.

Evaluation of clinical practice guidelines on fall prevention and management for older adults: a systematic review.

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Montero-Odasso MM, Kamkar N, Pieruccini-Faria F, et al. JAMA Netw Open. 2021;4:e2138911.

Fall prevention in healthcare settings is a patient safety priority. This systematic review found that most clinical practice guidelines provide consistent recommendations for fall prevention for older adults. Guidelines consistently recommend strategies such as risk stratification, medication review, and environment modification.

Medication safety issues with newly authorized PAXLOVID.

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Institute for Safe Medication Practices. Medication Safety Alerts. January 3, 2022.

Emerging care practices can produce unsafe situations due to the newness of the approaches involved. This alert highlights safety considerations with an oral antiretroviral COVID treatment that include medication administration problems. Safety recommendations are provided for prescribers and pharmacists.

In Conversation With... Poonam Sharma, MD, MPH, the Senior Clinical Data Analyst at Atrium Health, and Rhonda Dickman, MSN, RN, CPHQ, the Director of the Tennessee Hospital Association PSO

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Perspective on Safety January 12, 2022

Patient Safety Organizations (PSOs) are organizations dedicated to improving patient safety and healthcare quality that serve to collect and analyze data voluntarily reported by healthcare providers to promote learning.

Coronavirus Disease 2019 (COVID-19) and Diagnostic Error

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Patient Safety Primer January 11, 2022

Diagnostic error has been increasingly recognized as an important and evolving patient safety issue. This Primer applies well-established principles of diagnostic error and improvement of diagnostic accuracy to the topic of COVID-19.

Veterans Health Administration Stratification Tool for Opioid Risk Mitigation (STORM) Shows Promise for Targeting Prevention Interventions to Reduce Mortality in Patients Who Are Prescribed Opioids

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Patient Safety Innovation January 7, 2022

The Veterans Health Administration (VHA) Stratification Tool for Opioid Risk Mitigation (STORM) decision support system and targeted prevention program were designed to help mitigate risk factors for overdose and suicide among veterans who are prescribed opioids and/or with opioid use disorder (OUD) and are served by the VHA.¹ Veterans, particularly those prescribed opioids, experience overdose and suicide events at roughly twice the rate of the general population.^1,2

The Next Step: Use of a Pre-Operative Checklist to Prevent Missteps

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WebM&M Case January 7, 2022

A 52-year-old woman presented for a lumpectomy with lymphoscintigraphy and sentinel lymph node biopsy (SLNB) after being diagnosed with ductal carcinoma in situ (DICS). On the day of surgery, the patient was met in the pre-operative unit by several different providers (pre-operative nurse, resident physician, attending physician, and anethesiology team) to help prepare her for the procedure. In the OR, the surgical team performed two separate time-outs while the patient was being prepped, placed under general anesthesia, and draped.

Prevalence of potentially harmful multidrug interactions on medication lists of elderly ambulatory patients.

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Anand TV, Wallace BK, Chase HS. BMC Geriatr. 2021;21:648.

Older adults, particularly those taking more than one medication, are at increased risk of adverse drug events (ADE). In this study of 6,545 older adult patients who were prescribed at least 3 medications, multidrug interactions (MDI) were identified in 1.3% of medication lists. Psychotropic medications were the most commonly involved medication class; the most common serious ADE were serotonin syndrome, seizures, prolonged QT interval, and bleeding.

Filling the gaps on the Institute for Safe Medication Practices (ISMP) Do Not Crush List for Immediate-release Products

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Uttaro E, Zhao F, Schweighardt A. Int J Pharm Compd. 2021;25(5):364-371.

Medication administration, particularly when it involves drug formulation manipulation, is a complex process. This study analyzed the products included on the Institute for Safe Medication Practices’ (ISMP) ‘Do Not Crush List’ and found that many presented no risk or low risk for crushing. The authors provide recommendations for clinicians to aid in clinical decision-making regarding crushing, such as suitable personal protective equipment and prompt administration.

Input for the TeamSTEPPS Curriculum Updates.

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Rockville MD, Agency for Healthcare Quality and Research. December 7, 2021.

The TeamSTEPPS program is an established approach for improving teamwork and communication in health care. This announcement calls for feedback from healthcare teams and team members on how to update the current TeamSTEPPS training curriculum.

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.

Understanding preventable deaths in the geriatric trauma population: analysis of 3,452,339 patients from the Center of Medicare and Medicaid Services Database.

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Ang D, Nieto K, Sutherland M, et al. Am Surg. 2022;88:587-596.

Patient safety indicators (PSI) are measures that focus on quality of care and potentially preventable adverse events. This study estimated odds of preventable mortality of older adults with traumatic injuries and identified the PSIs that are associated with the highest level of preventable mortality. Strategies to reduce preventable mortality in older adults are presented (e.g. utilization of national guidelines, minimization of central venous catheter use, addressing polypharmacy).

Factors influencing providers' willingness to deprescribe medications.

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Davila H, Rosen AK, Stolzmann K, et al. J Am Coll Clin Pharm. 2022;5:15-25.

Deprescribing is a patient safety strategy to reduce the risk of adverse drug events, particularly for patients taking five or more medications. Physicians, nurse practitioners, physician assistants, and clinical pharmacists in Veterans Affairs primary care clinics were surveyed about their beliefs, attitudes, and experiences with deprescribing. While most providers reported having patients taking potentially inappropriate or unnecessary medications, they did not consistently recommend deprescribing to their patients.

Malpractice cases in breast surgery: an assessment of litigation involving surgeons.

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Fan B, Pardo J, Yu-Moe CW, et al. Ann Surg Oncol. 2021;28:8109-8115.

While prior research has described malpractice cases related to breast cancer diagnosis and treatment, this study sought to identify errors specifically related to breast cancer surgical procedures. Plastic surgeons were the most commonly named provider type (64%), error in surgical treatment was the most common allegation (87%), and infection, cosmetic injury, emotional trauma, foreign body, and nosocomial infection were the top 5 injury descriptions.

Communication regarding adverse neonatal birth events: experiences of parents and clinicians.

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Loren DL, Lyerly AD, Lipira L, et al. J Patient Saf Risk Manag. 2021;26:200-206.

Effective communication between patients and providers – including after an adverse event – is essential for patient safety. This qualitative study identified unique challenges experienced by parents and providers when communicating about adverse birth outcomes – high expectations, powerful emotions, rapid change and progression, family involvement, multiple patients and providers involved, and litigious environment. The authors outline strategies recommended by parents and providers to address these challenges.

Culture Clash No More: Integration and Coordination of Disease Treatment and Palliative Care

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WebM&M Case November 30, 2021

A 77-year-old man was diagnosed with a rectal mass. After discussing goals of care with an oncologist, he declined surgical intervention and underwent targeted radiotherapy before being lost to follow up. The patient subsequently presented to Emergency Department after a fall at home and was found to have new metastatic lesions in both lungs and numerous enhancing lesions in the brain. Further discussions of the goals of care revealed that the patient desired to focus on comfort and on maintaining independence for as long as possible. The inpatient hospice team discussed the potential role

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