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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 88 Results
Sutherland A, Jones MD, Howlett M, et al. Drug Saf. 2022;45:881-889.
Intravenous (IV) medication smart pumps can improve medication administration, but usability issues can compromise safety. This article outlines strategic recommendations regarding the implementation of smart pump technology to improve patient safety. Recommendations include standardization of infusion concentrations, improving drug libraries using a human-centered approach, and increasing stakeholder engagement.
Curated Libraries
October 10, 2022
Selected PSNet materials for a general safety audience focusing on improvements in the diagnostic process and the strategies that support them to prevent diagnostic errors from harming patients.
Dzisko M, Lewandowska A, Wudarska B. Sensors (Basel). 2022;22:3536.
Interruptions and distractions in healthcare settings can inhibit safe care. This simulation study found that medical staff reaction time to changes in vital signs during stressful situations (telephone ringing, ambulance signal) was significantly slower than during non-stressful situations, which may increase the likelihood of medical errors.
Curated Libraries
January 14, 2022
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...
Koeck JA, Young NJ, Kontny U, et al. Front Pediatr. 2021;9:633064.
Medication safety in children is a patient safety priority. This systematic review explored interventions to reduce medication dispensing, administration, and monitoring errors in pediatric healthcare settings. The majority of identified studies used “administrative controls” to prevent errors, but those implementing higher-level interventions (such as smart pumps and mandatory barcode scanning) were more likely to result in error reduction.
Curated Libraries
September 13, 2021
Ensuring maternal safety is a patient safety priority. This library reflects a curated selection of PSNet content focused on improving maternal safety. Included resources explore strategies with the potential to improve maternal care delivery and outcomes, such as high reliability, care standardization,teamwork, unit-based safety initiatives, and...
Dryver E, Lundager Forberg J, Hård af Segerstad C, et al. BMJ Qual Saf. 2021;30:697-705.
Checklists are commonly used in surgical and critical care settings to improve patient safety. This multisite study simulation study found that checklists can improve local resuscitation teams’ management of medical crises such as anaphylactic shock and septic shock in emergency departments.
Mahadevan K, Cowan E, Kalsi N, et al. Open Heart. 2020;7.
Distractions and interruptions are common during delivery of health care. In this evaluation of 194 cardiac catheterization procedures at a single hospital, the authors found that fewer than half of all procedures were completed without interruption or distraction. The authors propose several actions such as the use of a ‘sterile cockpit’ to reduce distractions and improve patient safety.
Britton CR, Hayman G, Stroud N. J Perioper Pract. 2021;31:44-50.
The COVID-19 pandemic has highlighted the crucial role that team and human factors play in healthcare delivery. This article describes the impact of a human factors education and training program focused on non-technical skills and teamwork (the ONSeT project) – on operating room teams during the pandemic. Results indicate that the project improved team functioning and team leader responsiveness.
Alshahrani F, Marriott JF, Cox AR. Int J Clin Pharm. 2020;43:884-892.
Computerized provider order entry (CPOE) can prevent prescribing errors, but patient safety threats persist. Based on qualitative interviews with multidisciplinary prescribers, the authors identified several issues related to CPOE interacting within a complex prescribing environment, including alert fatigue, remote prescribing, and default auto-population of dosages.
Furniss D, Dean Franklin B, Blandford A. Health Inform J. 2020;26:576-591.
The authors conducted a sociotechnical investigation to describe the implementation of a closed-loop documentation system linked with smart pumps for intravenous infusion administration in one ICU. These types of closed-loop systems automate steps in the documentation of medication administration. In this case, the smart pumps were ‘mapped’ to an electronic prescribing and administration system. As a result, nurses do not need to manually enter these data after administration.
Fitzsimons J. Int J Qual Health Care. 2021;33:mzaa051.
This article discusses the importance of leveraging quality improvement and patient safety science in acute and emergency situations. Methods and tools such as rapid learning cycles, huddles, team-based approaches, and debriefing and their applications to the COVID-19 pandemic are discussed.
Kuitunen SK, Niittynen I, Airaksinen M, et al. J Patient Saf. 2021;17:e1669-e1680.
The objective of this systematic review was to identify systemic defenses (such as barcode scanning) to confirm drug and patient identity, clinical decision systems, and smart infusion pumps) to prevent in-hospital intravenous (IV) medication errors. Of the 46 included studies, most discussed systemic defenses related to drug administration; fewer discussed defenses during prescribing, preparation, treatment monitoring and dispensing. Closed loop medication management and smart pumps were the most common systemic defenses examined in the included studies; the authors identify a need for further studies exploring the effectiveness of different combinations of systemic defenses.
Parekh N, Ali K, Davies JG, et al. BMJ Qual Saf. 2020;29:142-153.
This study sought to develop a tool (PRIME) to predict the risk of post-discharge medication-related harm in older adults. The cohort was derived from inpatients at five hospitals in England and included 119 individuals who experienced medication-related harm requiring healthcare utilization and 699 individuals who did not experience a medication-related harm. Researchers found that the PRIME tool can accurately identify older at-risk patients and may help reduce medication-related harm and subsequent healthcare utilization.
Appelbaum N, Clarke J, Feather C, et al. BMJ Open. 2019;9:e032686.
While medication errors during paediatric resuscitation are considered common, little information about the processes that contribute to them has been gathered. This prospective observational study in a large English teaching hospital describes the incidence, nature and severity of medication errors made by 15 teams, each comprised of two doctors and two nurses, during simulated paediatric resuscitations. Clinically significant errors were made in 11 of the 15 cases, most due to discrepancies in drug ordering, preparation and administration. The authors recommend additional research into new approaches to protecting patients in paediatric emergency settings.
Dominguez ED, Rocos B. Cureus. 2019;11:e4877.
This analysis of the National Reporting and Learning Service database (the United Kingdom's voluntary error reporting system) identified numerous cases of patient harm due to malfunctioning surgical equipment, the most common involving unretrieved device fragments (such as broken drill bits). The authors contend that lack of a standardized reporting and tracking system for surgical instrument malfunctioning poses a potential threat to patients. A WebM&M commentary discussed an incident involving life-threatening hemorrhage due to a broken surgical instrument.
Ansari SP, Rayfield ME, Wallis VA, et al. J Patient Saf. 2020;16:e359-e366.
This study describes a multidisciplinary human factors training intervention for labor and delivery care that included communication training and simulation work. Researchers found that safety culture improved compared to preintervention scores.

Hallbeck MS, Paquet V, eds. Appl Ergon. 2019;78:248-308.

Surgery requires specialized approaches to understand and prevent failure. This special issue features the work of multidisciplinary research teams that explored human factors and ergonomic concerns in the operating room that affect communication between robotic-assisted surgery teams, physical resilience of teams, instrument design and use, and poor implementation of briefings as improvement opportunities.