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 390 Results

Use duodenoscopes with innovative designs to enhance safety: FDA Safety Communication.

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Silver Spring, MD: US Food and Drug Administration; April 5, 2022.

The challenge of medical device sterilization has shifted the design of some products with disposable elements in order to reduce opportunities for human error that increase infection potential during reuse. The publication supports the complete adoption of disposable duodenoscopes or scope components as a safety measure.

Intraosseous Line Extravasation in a Pediatric Trauma Patient

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WebM&M Case April 27, 2022

An 18-month-old girl presented to the Emergency Department (ED) after being attacked by a dog and sustaining multiple penetrating injuries to her head and neck. After multiple unsuccessful attempts to establish intravenous access, an intraosseous (IO) line was placed in the patient’s proximal left tibia to facilitate administration of fluids, blood products, vasopressors, and antibiotics. In the operating room, peripheral intravenous (IV) access was eventually obtained after which intraoperative use of the IO line was restricted to a low-rate fluid infusion.

Toolkit for Preventing CLABSI and CAUTI in ICUs.

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Rockville, MD: Agency for Healthcare Research and Quality; April 2022.

Healthcare-associated infections can result in significant morbidity and mortality. Developed by AHRQ, this customizable, educational toolkit uses the Comprehensive Unit-based Safety Program (CUSP) and other evidence-based practices to provide clinical and cultural guidance to support practice changes to prevent and reduce central line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) rates in intensive care units (ICUs). Sections of the kit include items such an action plan template, implementation playbook, and team interaction aids.

Implementing a robust process improvement program in the neonatal intensive care unit to reduce harm.

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Nether KG, Thomas EJ, Khan A, et al. J Healthc Qual. 2022;44:23-30.

Medical errors in the neonatal intensive care unit threaten patient safety. This children’s hospital implemented a robust process improvement program (RPI, which refers to widespread dissemination of process improvement tools to support staff skill development and identify sustainable improvements) to reduce harm in the neonatal intensive care unit. The program resulted in significant and sustainable improvements to staff confidence and knowledge related to RPI tools. It also contributed to improvements in health outcomes, including healthcare-acquired infection.

Economic evaluation of quality improvement interventions to prevent catheter-associated urinary tract infections in the hospital setting: a systematic review.

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McCleskey SG, Shek L, Grein J, et al. BMJ Qual Saf. 2022;31:308-321.

Catheter-associated urinary tract infection (CAUTI) prevention is an ongoing patient safety priority. This systematic review of economic evaluations of quality improvement (QI) interventions to reduce CAUTI rates found that QI interventions were associated with a 43% decline in infections.

Cost of health care-associated infections in the United States.

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Forrester JD, Maggio PM, Tennakoon L. J Patient Saf. 2022;18:e477-e479.

Healthcare-associated infections (HAIs) result in poorer patient outcomes and increased costs. The 2016 national data set of five common HAIs (surgical site infections, catheter- and line-associated bloodstream infections, catheter-associate urinary tract infections, ventilator-associated pneumonia, and Clostridioides difficile) was analyzed to create an estimated national cost. Clostridioides difficile was the most frequently reported; Clostridioides difficile and surgical site infections accounted for 79% of costs.

Health care safety during the pandemic and beyond--building a system that ensures resilience.

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Fleisher LA, Schreiber M, Cardo D, et al. N Engl J Med. 2022;386:609-611.

The COVID-19 pandemic disrupted many aspects of health care. This commentary discusses its impact on patient safety. The authors discuss how the pandemic response dismantled strategies put in place to prevent healthcare-associated infections and falls, and stressors placed on both patients and healthcare workers directed attention away from ongoing safety improvement efforts. They argue that more resilience needs to be built into the system to ensure safety efforts are sustainable in challenging times.

Coronavirus disease 2019 (COVID-19) pandemic, central-line-associated bloodstream infection (CLABSI), and catheter-associated urinary tract infection (CAUTI): the urgent need to refocus on hardwiring prevention efforts.

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Fakih MG, Bufalino A, Sturm L, et al. Infect Control Hosp Epidemiol. 2021;43:26-31.

Central line-associated blood steam infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) prevention were an important part of patient safety prior to the COVID-19 pandemic. This study compared CLABSI and CAUTI rates in 78 hospitals during the 12-month period prior to the pandemic and the first 6 months of the pandemic. CLABSI rates increased by 51% during the pandemic period, mainly in the ICU. CAUTI rates did not show significant changes.

Improving shared situation awareness for high-risk therapies in hospitalized children.

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Sosa T, Mayer B, Chakkalakkal B, et al. Hosp Pediatr. 2022;12:37-46.

Many medications and medical devices can result in preventable harm in pediatric patients. This article describes one hospital’s efforts to implement explicit, structured processes and huddles to increase situational awareness regarding high-risk therapies among the care team and family members. After implementation, the percentage of electronic health record (EHR) alerts correctly describing high-risk therapies increased from 11% to 96%.

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...

Causes of use errors in ventilation devices--systematic review.

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Coldewey B, Diruf A, Röhrig R, et al. Appl Ergon. 2021;98:103544.

Medical devices without user-friendly interface designs may contribute to patient complications. This review explores problems in the use and design of mechanical ventilators that challenge safe use. The authors provide recommendations to product engineers to improve safe ventilator design.

Anatomy of a medical device recall: How defective products can slip through an outdated system.

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Zipp R. Medical Tech Dive. October 18, 2021.

This article highlights systems influences that detract from the effectiveness of current methods of reporting recalled unsafe medical devices and raising awareness of recalls for clinicians, patients and families. Challenges highlighted include the use of paper-based notification systems and data reporting delays.

The Hidden Danger of Unseen Intravenous Catheters

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WebM&M Case October 27, 2021

A 6-week-old infant underwent a craniotomy and excision of abnormal brain tissue for treatment of hemimegalencephaly and epilepsy.

Potential for medication overdose with ENFit low dose tip syringe: FDA Safety Communication.

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MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; October 12, 2021.

This announcement highlights the possibility of medication administration inaccuracy due to design characteristics of a low dose tip (LDT) syringe. Recommended cleaning methods and other actions for patients, families and clinicians are provided to protect dose precision when using these syringes.

Device use errors among patients with asthma and COPD and the role of training: a real-life study.

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Papaioannou AI, Bartziokas K, Hillas G, et al. Postgrad Med. 2021;133:524-529.

Incorrect use of medical devices can lead to unfavorable outcomes. In this study of 663 patients with asthma and/or chronic obstructive pulmonary disease (COPD), 41% demonstrated incorrect use of their inhaler. Incorrect use was more common among older patients and associated with more acute exacerbations.

Cardinal Health recalls Argyle UVC insertion tray due to missing instructions for use for the Safety Scalpel N11.

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MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; August 20, 2021.

Delays in treatment due to device misuse or design flaws can result in patient harm. This recall announcement highlights the omission of instructions describing a distinct device feature that, if a surgeon is unaware of it, reduces emergent umbilical vein catheter placement safety. Two deaths have been reported due to problems with the device.

Influence of organizational climate and clinician morale on seclusion and physical restraint use in inpatient psychiatric units.

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Anderson E, Mohr DC, Regenbogen I, et al. J Patient Saf. 2021;17:316-322.

Burnout and low staff morale have been associated with poor patient safety outcomes. This study focused on the association between organizational climate, burnout and morale, and the use of seclusion and restraints in inpatient psychiatric hospitals. The authors recommend that initiatives aimed at reducing restraints and seclusion in inpatient psychiatric facilities also include a component aimed at improving organizational climate and staff morale.

FDA Safety Communication: update--robotically-assisted surgical devices in mastectomy.

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MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; August 20, 2021.

This announcement seeks to raise awareness of the potential risks associated with the use of robotic-assisted surgical devices in mastectomies or cancer-related care. Recommendations for patients who may seek to have robotically assisted surgery include asking about their surgeon's experience with these procedures and discussing benefits, risks, and alternatives regarding available treatment options with their health care provider. Suggestions for health care providers include completing specialized training on procedures they perform. A WebM&M commentary described the challenges and benefits associated with robotic surgery.

Safety committees need to proactively address the risk of accidental cerebral injection of intravenous (IV) drugs.

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ISMP Medication Safety Alert! Acute care edition. July 29, 2021;26(15);1-5.

Tubing misconnections have been associated with medication administration errors, and yet, design strategies to minimize these mistakes are only beginning to be uniformly implemented. This article shares the story of a contrast media administration error associated with communication and handoff errors. The piece recommends focusing on universal design standards to improve administration along with clinical steps to mitigate the potential for this type of error.

Reporting of death in US Food and Drug Administration medical device adverse event reports in categories other than death.

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Lalani C, Kunwar EM, Kinard M, et al. JAMA Intern Med. 2021;181:1217-1223.

Medical device-associated errors are common and often result in preventable patient harm. Based on medical device adverse event data reported to the FDA's Manufacturer and User Facility Device Experience (MAUDE), this study used natural language processing to identify events not classified as deaths even though the patient died. Findings suggest that approximately 17% of medical device events that resulted in death were classified in other categories.

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