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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 - 6 of 6 Results
Washington DC; American Society of Hematology.
The American Society of Hematology produced a series of guidelines on prophylaxis for venous thromboembolism, which can be a patient safety problem among hospitalized patients. Key recommendations include low-molecular-weight heparin as the preferred agent when medication prophylaxis is indicated and screening of all hospitalized patients for venous thromboembolism risk and bleeding.
Kane-Gill SL, Dasta JF, Buckley MS, et al. Crit Care Med. 2017;45:e877-e915.
Although technology has helped decrease medication errors, adverse drug events remain a significant source of harm. Patients in the intensive care unit (ICU) may be particularly vulnerable to medication errors due to the complex nature of their care. Prior research has shown that medication errors occur more frequently in the ICU and are more likely to cause serious patient harm or death. This clinical practice guideline highlights environmental changes and prevention strategies that can be employed to improve medication safety in the ICU. The authors also describe components of active surveillance that may augment detection of medication errors and adverse drug events. A previous WebM&M commentary discussed a case involving a serious medication error in the ICU setting.
Busse JW, Craigie S, Juurlink DN, et al. CMAJ. 2017;189:E659-E666.
Opioid pain medications carry high risk for adverse drug events, and opioid misuse is a growing patient safety concern. This guideline provides recommendations to augment safe prescribing of these high-risk medications for patients with chronic noncancer pain.
Michaels AD, Spinler SA, Leeper B, et al. Circulation. 2010;121.
Patients hospitalized with acute coronary syndromes or strokes are particularly vulnerable to medication errors, as many of these patients are elderly, have complex medication regimens, or are administered high-risk medications such as anticoagulants. This position paper from the American Heart Association reviews the specific types of medication errors in these patients, including dosing errors, administration of contraindicated medications, and errors of omission (failure to prescribe recommended therapies). The authors make specific, evidence-based recommendations for preventing medication errors in this patient population, including integrating pharmacists into inpatient teams and using computerized provider order entry and medication reconciliation to detect and prevent errors. A medication error in an acute coronary syndrome patient is illustrated in this AHRQ WebM&M commentary.
Polovich M; Blecher CS; Glynn-Tucker EM; McDiarmid M; Newton SA
This guideline provides recommendations to enhance the safe delivery of high-risk medications. Topics include assessing occupational exposure risks, engineering controls, work practice controls, safety measures, drug administration, and postadministration practices.

Stucky ER; American Academy of Pediatrics Committee on Drugs; American Academy of Pediatrics Committee on Hospital Care. Pediatrics. 2003;112(2):431-436.

Key areas of recommendations to improve medication safety are reviewed: hospital-wide system actions and guidelines, prescriber actions and guidelines, and education and communication for prescribers, nurses, pharmacists, patients, and families.