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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 57 Results
Derrong Lin I, Hertig JB. Hosp Pharm. 2022;57:323-328.
The COVID-19 pandemic necessitated urgent changes in all clinical settings including community and hospital pharmacies. This commentary describes global threats to patient safety (rapidly changing clinical evidence, counterfeit medications, drug shortages) and strategies pharmacy leaders can implement to maintain patient safety.
Galiatsatos P, O'Conor KJ, Wilson C, et al. Health Secur. 2022;20:261-263.
Stressful situations can degrade communication, teamwork and decision making. This commentary describes a program to minimize the potential impact of implicit biases in a crisis. Steps in the process include Pausing to Listen, working to Ally and Collaborate, and seeking to Empower patients and staff members.
Mahomedradja RF, van den Beukel TO, van den Bos M, et al. BMC Emerg Med. 2022;22:35.
The potential for medication errors may increase due to redeployment and reorganization of hospital resources during COVID-19 surges. In this study of patients hospitalized during the first wave of the pandemic, over 90% had at least one prescribing error three months after hospitalization. Intensive care unit admission and a history of chronic obstructive pulmonary disease (COPD) or asthma were risk factors for prescribing errors. Acknowledging and understanding these risk factors allows hospital leadership to target interventions for this population.
Labrague LJ, Santos JAA, Fronda DC. J Nurs Manag. 2022;30:62-70.
Missed or incomplete nursing care can adversely affect care quality and safety. Based on survey responses from 295 frontline nurses in the Philippines, this study explored factors contributing to missed nursing care during the COVID-19 pandemic. Findings suggest that nurses most frequently missed tasks such as patient surveillance, comforting patients, skin care, ambulation, and oral hygiene. The authors suggest that increasing nurse staffing, adequate use of personal protective equipment, and improved safety culture may reduce instances of missed care.  
Perspective on Safety January 12, 2022

Patient Safety Organizations (PSOs) are organizations dedicated to improving patient safety and healthcare quality that serve to collect and analyze data voluntarily reported by healthcare providers to promote learning.

Fatemi Y, Coffin SE. Diagnosis (Berl). 2021;8:525-531.
Using case studies, this commentary describes how availability bias, diagnostic momentum, and premature closure resulted in delayed diagnosis for three pediatric patients first diagnosed with COVID-19. The authors highlight cognitive and systems factors that influenced this diagnostic error.
Marziliano A, Burns E, Chauhan L, et al. J Gerontol A Biol Sci Med Sci. 2022;77:e124-e132.
Many COVID-19 patients present with atypical symptoms, such as delirium, smell and taste dysfunction, or cardiovascular features. Based on inpatient electronic health record data between March 1 and April 20 of 2020, this cohort study examined the frequency of atypical presentation of COVID-19 among older adults. Analyses suggest that atypical presentation was often characterized by functional decline or altered mental status.
Li Q, Hu P, Kang H, et al. J Nutr Health Aging. 2020;25:492-500.
Missed and delayed diagnosis are a known cause of preventable adverse events. In this cohort of 107 patients with severe or critical COVID-19 in Wuhan, China, 45% developed acute kidney injury (AKI). However, nearly half of those patients (46%) were not diagnosed during their stay in the hospital. Patients with undiagnosed AKI experienced greater hospital mortality than those without AKI or diagnosed AKI. Involvement of intensive care kidney specialists is recommended to increase diagnostic awareness.
WebM&M Case April 28, 2021

A pregnant patient was admitted for scheduled Cesarean delivery, before being tested according to a universal inpatient screening protocol for SARS-CoV-2. During surgery, the patient developed a fever and required oxygen supplementation. Due to suspicion for COVID-19, a specimen obtained via nasopharyngeal swab was sent to a commercial laboratory for reverse transcriptase polymerase chain reaction (RT-PCR) testing.

Cattaneo D, Pasina L, Maggioni AP, et al. Drugs Aging. 2021;38:341-346.
Older adults are at increased risk of hospitalization due to COVID-19 infections. This study examined the potential severe drug-drug interactions (DDI) among hospitalized older adults taking two or more medications at admission and discharge. There was a significant increase in prescription of proton pump inhibitors and heparins from admission to discharge. Clinical decision support systems should be used to assess potential DDI with particular attention paid to the risk of bleeding complications linked to heparin-based DDIs.

Issue Brief. Washington DC: Pew Charitable Trust; March 2021.

Antibiotic overuse is a contributor to nosocomial infection. This report discusses problems associated with antibiotic prescribing during the first 6 months of the COVID-19 pandemic. Systemic problems arising from the situation include disparities associated with antibiotic administration and unneeded receipt of medications by some patients.
Mulchan SS, Wakefield EO, Santos M. J Ped Psychol. 2021;46:138-143.
Implicit and explicit bias can reduce the effectiveness and safety of care. Based on a review of the literature, the authors conclude that the strain placed on provider resources, staff, and supplies by the COVID-19 pandemic may exacerbate implicit bias among pediatric providers. The authors discuss implicit bias at the individual, organizational, educational, and research levels, provide specific calls to action for pediatric healthcare providers, and discuss the role of pediatric psychologists in supporting other providers.

ISMP Medication Safety Alert! Acute Care Edition. January 14, 2021;26(1);1-5. 
 

Learning from error rests on transparency efforts buttressed by frontline reports. This article examined reports of COVID-19 vaccine errors to highlight common risks that are likely to be present in a variety of settings and share recommendations to minimize their negative impact, including storage methods and vaccination staff education. 
Ebm C, Carfagna F, Edwards S, et al. J Crit Care. 2020;62:138-144.
Prescribing medications for indications that are not approved by the Food and Drug Administration (FDA) is common but poses a risk for medication errors. The authors of this study used simulation modeling to explore the influence of physician personal preference on off-label medication use during the COVID-19 pandemic.  
Kozasa EH, Lacerda SS, Polissici MA, et al. Front Psych. 2020;11:570786.
Situational awareness during critical incidents is a key component of teamwork. This study found that a mutual care training can increase situational awareness for healthcare workers and consequently improve mental health and well-being before and during the COVID-19 pandemic.

March 2020--January 2021.

Medication safety is improved through the sharing of frontline improvement experiences and concerns. These articles share recommendations to reduce risks associated with distinct areas of the medication use process. The topics discuss areas that require specific attention during the COVID-19 pandemic such as the use of smart pumps and automated dispensing cabinets.
Butler CR, Wong SPY, Wightman AG, et al. JAMA Netw Open. 2020;3:e2027315.
The COVID-19 pandemic has led to wide-ranging changes to health care delivery. This qualitative study with clinicians in the United States identified three emerging themes describing clinicians’ experience providing care in settings of resource limitations - planning for crisis capacity, adapting to resource limitations, and unprecedented barriers to care delivery.