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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 - 11 of 11 Results
Cicero MX, Adelgais K, Hoyle JD, et al. Prehosp Emerg Care. 2020;25:294-306.
This position statement shares 11 recommendations drawn from a review of the evidence to improve the safety of pediatric dosing in pre-hospital emergent situations. Suggestions for improvement include use of kilograms as the standard unit of weight, pre-calculated weight-based dosing, and dose-derivation strategies to minimize use of calculations in real time.   
Gallagher R, Passmore MJ, Baldwin C. Med Hypotheses. 2020;142:109727.
The authors of this article suggest that offering palliative care services earlier should be considered a patient safety issue. They highlight three cases in which patients in Canada requested medical assistance in dying (MAiD). The patients in two of the cases were never offered palliative care services, and this could be considered a medical error – had they been offered palliative care services, they may have changed their mind about MAiD, as did the patient in the third case study.
Frakt A. New York Times. August 26, 2019.
The slow adoption of improvement innovations is a persistent challenge to high-quality and safe patient care. This newspaper article raises concerns about how common treatments are recommended despite insufficient evidence regarding their effectiveness and provides examples of how this problem can result in harm, such as the previous physician belief that opioids were not addictive. Reassessment of science can improve safety and reduce the unintended consequences of ineffective treatments.
Soffin EM, Lee BH, Kumar KK, et al. Br J Anaesth. 2019;122:e198-e208.
Reducing opioid prescribing in pain management is a key strategy to address the opioid crisis. This review highlights the unique role of the anesthesiologist in this approach. The authors emphasize preoperative identification of patients at risk for long-term opioid use and suggest organizational, clinical, and research strategies that can be led by anesthesiologists to reduce opioid use.
Mark TL, Parish W. J Subst Abuse Treat. 2019;103:58-63.
In this retrospective analysis of Medicaid claims, researchers found that opioid medications are often discontinued abruptly, presumably for safety reasons. Nearly half of patients who had opioids suddenly discontinued or with short tapering lengths experienced an opioid-related emergency department visit and hospitalization, suggesting an unintended consequence of reducing opioid use.
Dahlke SA, Hunter KF, Negrin K. Int J Older People Nurs. 2019;14:e12220.
Care for older hospitalized patients can be complex due to multimorbidities and polypharmacy. This review found that restraint use and limiting mobility to prevent falls can result in functional losses in geriatric patients. The authors suggest multidisciplinary approaches to shifting the goals of nursing care to focus on preserving and restoring function in older patients.
Rubin R. JAMA. 2019;321:2059-2062.
Patients with chronic pain can experience unintended consequences related to prescription limitation policies implemented to address the opioid epidemic. This commentary offers insights from primary care providers and regulators regarding the difficulty of managing opioid prescriptions to limit misuse while effectively treating pain.
Sheetz KH, Dimick JB. JAMA. 2019;321:1971-1972.
The FDA recently raised awareness of the potential risks associated with the use of robotic-assisted surgical devices in mastectomies or cancer-related care. This commentary spotlights how payers, hospitals, and clinicians can prevent harm related to robotic surgical device use. Strategies to improve safety include enhanced credentialing, device-specific training, and informed consent. A WebM&M commentary discussed an incident of harm associated with robotic-assisted surgery.
Sun E, Mello MM, Rishel CA, et al. JAMA. 2019;321:762-772.
Scheduling overlapping surgeries has raised substantial patient safety concerns. However, research regarding the impact of concurrent surgery on patient outcomes has produced conflicting results. In this multicenter retrospective cohort study, researchers examined the relationship between overlapping surgery and mortality, postoperative complications, and surgery duration for 66,430 surgeries between January 2010 and May 2018. Although overlapping surgery was not significantly associated with an increase in mortality or complications overall, researchers did find a significant association between overlapping surgery and increased length of surgery. An accompanying editorial discusses the role of overlapping surgery in promoting the autonomy of those in surgical training and suggests that further research is needed to settle the debate regarding the impact of overlapping surgery on patient safety.

Lau F, Bartle-Clar JA, Bliss G, et al, eds. Stud Health Technol Inform. 2019;257:1-539. ISBN: 9781614999508.

Information technology is prevalent in health care and is associated with both optimized processes and unintended consequences. This publication is a compilation of papers from an international conference that explored the potential of health information technology and the research needed to achieve success. Topics covered include usability, implementation, interoperability, and policy.