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.
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...
Hado E, Friss Feinberg L. J Aging Soc Policy. 2020;32:410-415.
These authors discuss the role of family caregivers during the COVID-19 pandemic and suggest avenues to support the relationship between families and residents of long-term care facilities, including strengthening communicating channels, activating family councils, and utilizing gerontological social work students.
Gordon M. Health Shots. National Public Radio. April 10, 2019.
Punitive responses to medical errors persist despite continued efforts to reduce them. This news article reports on an incident involving the mistaken use of a neuromuscular blocking agent that resulted in the death of a patient, the prosecution of the nurse who made the error, and systemic and human factors that contribute to similar events.
Nursing home patients are vulnerable to preventable harm due to poor safety culture, insufficient staffing levels, lack of regulation enforcement, and misaligned financial incentives. This news investigation reports on how poor practices resulted in resident harm in Pennsylvania nursing homes and discusses strategies for improvement, such as enhancing investigation processes.
Doucette E, Fazio S, LaSalle V, et al. Dynamics. 2010;21:16-9.
This article reports how nurses followed Canadian Disclosure Guidelines in disclosing sentinel events to patients and families and describes the benefits of using such guidelines for these discussions.
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