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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 2880 Results

Meyer TA. Anesthesiology News. October 31, 2022.

Medication use in the surgical environment is complex and high-risk. This article describes steps toward the implementation of medication safety process improvement programs for the operating room. Important steps discussed include assessment, analysis, planning, and implementation.
Johansen JS, Halvorsen KH, Svendsen K, et al. BMC Health Serv Res. 2022;22:1290.
Reducing unplanned hospital readmissions is a priority patient safety focus, and numerous interventions with hospital pharmacists have been developed. In this study, hospitalized adults aged 70 years and older were randomized to receive standard care or the IMMENSE intervention. The IMprove MEdicatioN Safety in the Elderly (IMMENSE) intervention is based on the integrated medicine management (IMM) model and consists of five steps, including medication reconciliation, patient counseling, and communication with the patient’s primary care provider. There was no significant difference in emergency department visits or readmissions between control and intervention within 12 months of the index hospital visit.
Perspective on Safety November 16, 2022

Dr. Pascale Carayon, PhD, is a professor emerita in the Department of Industrial and Systems Engineering and the founding director of the Wisconsin Institute for Healthcare Systems Engineering (WIHSE). Dr. Nicole Werner, PhD, is an associate professor in the Department of Health and Wellness Design at the Indiana University School of Public Health-Bloomington. We spoke with both of them about the role of human factors engineering has in improving healthcare delivery and its role in patient safety.

Wilson M-A, Sinno M, Hacker Teper M, et al. J Patient Saf. 2022;18:680-685.
Achieving zero preventable harm is an ongoing goal for health systems. In this study, researchers developed a five-part strategy to achieve high-reliability and eliminate preventable harm at one regional health system in Canada – (1) engage leadership, (2) develop an organization-specific patient safety framework, (3) monitor specific quality aims (e.g., high-risk, high-cost areas), (4) standardize the incident review process, including the use of root cause analysis, and (5) communicate progress to staff in real-time via electronic dashboards. One-year post-implementation, researchers observed an increase in patient safety incident reporting and improvements in safety culture, as well as decreases in adverse events such as falls, pressure injuries and healthcare-acquired infections.
Dowell D, Ragan KR, Jones CM, et al. MMWR Recomm Rep. 2022;71:1-95.
In 2016, the Centers for Disease Control and Prevention (CDC) released guidelines for safe opioid prescribing for chronic pain. Based on an updated evidence review, the CDC has revised the guidelines and released the Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022, include recommendations for outpatient acute, subacute, and chronic opioid use. The twelve recommendations fall into four broad categories: determining whether or not to initiate opioids for pain; selecting opioids and determining opioid dosages; deciding duration of initial opioid prescription and conducting follow-up; and assessing risk and addressing potential harms of opioid use. The CDC will update and develop tools and resources to support dissemination of these guidelines. The recommendations do not apply to pain related to sickle cell disease or cancer or to patients receiving palliative or end-of-life care, or for patients in the emergency department or admitted to the hospital.
Iturgoyen Fuentes DP, Meneses Mangas C, Cuervas Mons Vendrell M. Eur J Hosp Pharm. 2022;Epub Sep 30.
Medication reconciliation at hospital admission has reduced medication errors, but less is known about the pediatric population, particularly which patients may benefit most from reconciliation. This retrospective study of pediatric patients who experienced at least one medication reconciliation error found children older than 5 years, taking 4 or more medications, or with neurological or onco-hematological conditions were at increased risk of errors. Prioritization of these populations may improve the effectiveness of medication reconciliation.

Schneider E, Koretz BK, eds. Clin Geriatr Med. 2022;38(4):621-732.

Polypharmacy is a known contributor to medication complexity and error. This special issue examines the impact unnecessary medications have in a variety of care environments, such as nursing homes and emergency departments, and clinical areas, such as oncology and behavioral health.

Institute for Safe Medication Practices.

Mixed case letters are one suggested strategy to reduce look-alike medication name errors. This survey announcement calls for insight from the field to update an existing resource of problematic drug name pairs and examine the effectiveness of mixed case letter use to minimize confusion. The deadline for comment submission is December 2, 2022.
Laing L, Salema N-E, Jeffries M, et al. PLoS ONE. 2022;17:e0275633.
Previous research found that the pharmacist-led IT-based intervention to reduce clinically important medication errors (PINCER) can reduce prescription and medication monitoring errors. This qualitative study explored patients’ perceived acceptability of the PINCER intervention in primary care. Overall perceptions were positive, but participants noted that PINCER acceptability can be improved through enhanced patient-pharmacist relationships, consistent delivery of PINCER-related care, and synchronization of medication reviews with prescription renewals.
Shawahna R, Jaber M, Jumaa E, et al. J Patient Saf. 2022;18:e1047-e1060.
Medication errors in pediatric anesthesiology are common and largely preventable. This scoping review characterizing medication errors in pediatric anesthesia found that dosing errors were the most common. Recommendations to minimize or prevent medication errors in pediatric anesthesia commonly related to improving medication administration and documentation.
Krvavac S, Jansson B, Bukholm IRK, et al. Int J Environ Res Public Health. 2022;19:10686.
Inpatient suicide is sentinel event. This study examined treatment patterns among patients undergoing inpatient or outpatient psychiatric treatment who died by suicide. The research team found that patients who were primarily treated with medications were less likely to be sufficiently monitored, whereas patients who received both psychotherapy and medication were more likely to receive inadequate treatment.
Lauffenburger JC, Coll MD, Kim E, et al. Med Educ. 2022;56:1032-1041.
Medication errors can be common among medical trainees. Using semi-structured qualitative interviews, this study identified factors influencing suboptimal prescribing by medical residents during overnight coverage, including time pressures, perceived pressure and fear of judgement, clinical acuity, and communication issues between care team members.
Rockville, MD: Agency for Healthcare Research and Quality.
In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. The 2022 report discusses a decrease in life expectancy due to the COVID-19 pandemic. It also reviews the current status of special areas of interest such as maternity care, child and adolescent mental health, and substance abuse disorders. 
Trout KE, Chen L-W, Wilson FA, et al. Int J Environ Res Public Health. 2022;19:12525.
Electronic health record (EHR) implementation can contribute to safe care. This study examined the impact of EHR meaningful use performance thresholds on patient safety events. Researchers found that neither full EHR implementation nor achieving meaningful use thresholds were associated with a composite patient safety score, suggesting that hospitals may need to explore ways to better leverage EHRs and as well other strategies to improve patient safety, such as process improvement and staff training.
Saini S, Leung V, Si E, et al. BMJ Qual Saf. 2022;31:787-799.
Antimicrobial stewardship is an important element of patient safety. This scoping review explored how antimicrobial indication documentation can impact antibiotic use and clinical outcomes. The authors conclude that this is a growing area of research interest and note that emerging evidence indicates that appropriate antimicrobial indication documentation can improve prescribing and patient outcomes but that larger trials are needed to provide more robust evidence.
Lusk C, Catchpole K, Neyens DM, et al. Appl Ergon. 2022;104:103831.
Tall Man lettering and color-coding of medication syringes provide visual cues to decrease medication ordering and administration errors. In this study, an icon was added to the standard medication label; participants were asked to identify four medications, with and without the icon, from pre-defined distances. Participants correctly identified the medications with icons slightly more often.
Beerlage-Davids CJ, Ponjee GHM, Vanhommerig JW, et al. Int J Clin Pharm. 2022;Epub Oct 15.
Older adults taking multiple medications are at increased risk for adverse drug events following hospital discharge. In this study, patients were contacted two weeks after hospital discharge to evaluate adverse events, adverse drug events, and health-related quality of life (HRQoL). There was a weak but significant correlation between patient-reported adverse events and HRQoL, but not patient-reported adverse drug events.  
Roberts TJ, Sellars MC, Sands JM, et al. JCO Oncol Pract. 2022;Epub Sep 1.
Missed diagnosis of infectious diseases can have serious consequences for patient safety. This article describes a delayed diagnosis of disseminated tuberculosis in a patient with lung cancer and discusses the how cognitive biases and systems failures contributed to the diagnostic error.
Punj E, Collins A, Agravedi N, et al. Pharmacol Res Perspect. 2022;10:e01007.
Pharmacists play an important role in preventing medication errors. This systematic review identified 17 studies showing that pharmacy teams working in acute or emergency medicine departments can reduce medication errors through medication reconciliation.