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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 37 Results
DeLaurentis P, Walroth TA, Fritschle AC, et al. Am J Health Syst Pharm. 2019;76:1281-1287.
Smart infusion pumps have the potential to improve medication safety, but research suggests that errors remain common and that careful consideration must be given to both design and implementation of such technology. Researchers conducted a survey of five health systems in Indiana to better understand smart infusion pump users' views and knowledge regarding the drug library update process. They identified significant knowledge gaps, especially around the steps necessary to update the drug library.
Pinkney SJ, Fan M, Koczmara C, et al. Crit Care Med. 2019;47:e597-e601.
This simulation study examined critical care unit nurses' performance in identifying intravenous medications using different equipment types. Researchers found that line labels (attached to each line of tubing) and organizers (which prevent tubing from tangling) significantly improved the accuracy of medication identification compared to usual care. Use of smart pumps required more time and did not improve medication identification accuracy, suggesting that line labels and organizers are an inexpensive and feasible method to enhance medication safety.
Hsu K-Y, DeLaurentis P, Bitan Y, et al. J Patient Saf. 2019;15:e8-e14.
Smart infusion pumps store drug safety information, but this data must be periodically updated. This study demonstrated significant delays in updating the drug information for smart infusion pumps. These delays resulted in failure to alert for two high-risk medication cases, but neither case led to patient harm.
WebM&M Case March 1, 2019
A woman with multiple myeloma required placement of a central venous catheter for apheresis. The outpatient oncologist intended to order a nontunneled catheter via computerized provider order entry but accidentally ordered a tunneled catheter. The interventional radiologist thought the order was unusual but didn't contact the oncologist. A tunneled catheter was placed without complications. When the patient presented for apheresis, providers recognized the wrong catheter had been placed, and the patient underwent an additional procedure.
Bowdle TA, Jelacic S, Nair B, et al. Br J Anaesth. 2018;121:1338-1345.
This pre–post study of errors in anesthesia compared self-reported errors before and after implementation of a medication safety bundle that included smart infusion devices and barcode medication administration. Wrong-medication errors declined after barcoding was introduced, consistent with prior studies.
Lawal OD, Mohanty M, Elder H, et al. Expert Opin Drug Saf. 2018;17:347-357.
This study reviewed mandatory reporting of patient-controlled analgesia device-related events to the Food and Drug Administration postmarketing surveillance database. Less that 10% of reported events were deemed adverse events, and the vast majority of these were preventable. The authors call for development and adoption of patient-controlled analgesia devices with improved safety features and better training.
Giuliano KK. Crit Care Nurs Clin North Am. 2018;30:215-224.
Usability weaknesses can contribute to intravenous medication administration errors. This review explores problems in the design and use of intravenous smart pumps that challenge safe use. The author recommends employing innovation with an emphasis on human factors engineering to improve smart pump safety and usability.

ISMP Medication Safety Alert! Acute Care Edition. May 31, 2018;23:1-4.

Smart pumps offer both benefits and drawbacks that can affect medication safety. This newsletter article explores missteps related to lack of compliance with setting hard stops to protect patients when using unique intravenous medication concentrations. Recommendations to prevent errors include using standardized dosing concentrations as often as possible, adhering to metric unit dosing requirements, and verifying pump programming settings.
Perspective on Safety May 1, 2016
Dr. Drew is the David Mortara Distinguished Professor of Physiological Nursing and Clinical Professor of Medicine in Cardiology at the University of California, San Francisco. We spoke with her about the perils and prevalence of alert fatigue.
Schnock KO, Dykes PC, Albert J, et al. BMJ Qual Saf. 2017;26:131-140.
Medication errors associated with intravenous smart pumps are a safety concern. Because errors are not always reported, the magnitude of this problem has been unknown. In this study, direct observation of nurses using smart pumps revealed that 60% of medication infusions involved one or more errors, but actual harm to patients was rare. The most common errors involved incorrect infusion rates and workarounds like bypassing the smart pump. These results accentuate a need for improvements in smart pump design to enhance safety and usability. A previous WebM&M commentary describes consequences of an incorrect medication infusion.
Simmons D, Symes L, Guenter P, et al. Nutr Clin Pract. 2011;26:286-293.
Analyzing published case studies on tubing misconnections and expert recommendations for improvement, this review suggests that equipment redesign—making enteral and IV systems incompatible—is the most effective strategy to reduce incidence of such errors.
Paul JE, Bertram B, Antoni K, et al. Anesthesiology. 2010;113:1427-32.
Patient-controlled analgesia (PCA) is generally quite safe, but prior studies have shown that errors associated with PCA frequently result in patient harm. Due to several critical incidents associated with PCA errors, this Canadian hospital system implemented a multifaceted safety program including use of smart infusion pumps, standardized order sets, and mandatory error reporting. These interventions resulted in a significant reduction in PCA errors, chiefly by reducing pump programming errors (the most common type of error before the intervention). A PCA error with devastating clinical consequences is discussed in an AHRQ WebM&M commentary.