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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 62 Results
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.
Rabin RC. New York Times. October 14, 2019.
Drug shortages create potential complexities in drug therapy that can result in unsafe medication use. This story examines a vincristine shortage affecting pediatric patients.  Systemic factors contributing to the problem discussed include medications produced by a single supplier and workarounds when supplies are threatened. 
Alpert A, Jacobson M. Clin Pharmacol Ther. 2019;106:415-421.
Drug shortages have become more frequent and may lead to delays in treatment or failure to deliver the appropriate drug, an error of omission. This secondary data analysis examined how oncology drug shortages affected use of chemotherapy medications among patients with newly diagnosed cancer as measured by Medicare claims data. The changes in utilization varied by medication; overall, drug shortages had only a modest impact on the delivery of these drugs to patients with newly diagnosed cancer. This finding contrasts with a prior study showing patient harm related to drug shortages, and the authors recommend further study to understand how to identify and mitigate clinically relevant drug shortages. A WebM&M commentary discussed strategies for preventing or minimizing adverse events associated with drug shortages.
Banerjee R, Thurm CW, Fox ER, et al. Pediatrics. 2018;142.
Drug shortages can disrupt care processes and diminish medication safety. This commentary highlights distinct concerns associated with disruptions in access to appropriate antibiotics for pediatric patients and the lack of evidence exploring this common problem. The authors suggest strategies to address these shortages, including antibiotic stewardship and government oversight. A WebM&M commentary discussed challenges associated with medication shortages.
WebM&M Case October 1, 2018
A 1-month-old preterm infant in the NICU receiving the standard 500 mL bag of 0.45% sodium chloride (NaCl) with heparin at low rates developed hyponatremia. Clinicians recognized the need to deliver a more concentrated sodium solution and ordered that the IV fluid be changed to a 500 mL bag of 0.9% NaCl with heparin. However, due to a natural disaster affecting the supply chain for IV fluids, 0.9% NaCl 500 mL bags were in short supply, and the order was modified to use 100 mL 0.9% NaCl bags, which were available.
Rodriguez R. Hosp Pharm. 2018;53:408-414.
The Third Consensus Development Conference on the Safety of Intravenous Drug Delivery Systems convened in 2018 to evaluate the progress of intravenous (IV) drug safety since the 2009 conference. This review summarizes guideline changes regarding compounded sterile preparations (CSPs), new legislation, recommended best practices, workflow automation, and the impact of drug shortages. At the conference, the two most significant threats to IV drug safety were drug shortages and lack of standardization. The panel developed 10 overarching statements regarding safe IV drug safety including developing and strengthening a culture of safety.
Fox ER, McLaughlin MM. Am J Health Syst Pharm. 2018;75:1742-1750.
Drug shortages are a persistent threat to safe patient care. These guidelines provide a structured approach for care teams to develop an action plan to reduce risks when faced with drug shortages in their work. Recommendations include conducting operational assessments, establishing a drug shortage team, and communicating with patients and providers when a shortage occurs.
Am J Health Syst Pharm. 2018;75:816-820.
This commentary summarizes the discussion of a multidisciplinary group of experts about drug shortages to highlight successes, opportunities for improvement, trends to consider, and strategies to plan for shortages. The group recommended actions needed to guide prevention and mitigation efforts such as developing best practices for use of high-alert drugs during shortages, increasing manufacturer transparency, and enhancing Food and Drug Administration improvement and communication activities.
National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American Society of Health-System Pharmacists. May 24, 2018.
Drug shortages can necessitate hospitals to find alternative sources for important medications. This alert raises awareness of risks associated with potassium chloride use due to variations in labeling, packaging, or concentration of outsourced medications. Recommendations include use of barcode scanning and communicating with staff regarding drug shortages.