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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 679 Results

Salvon-Harman J. Healthcare Executive. 2023;39(3):48-49.

A strong safety work environment is core to reliable care delivery and staff wellbeing. This article discusses how leadership should listen broadly, embody accountability, support disclosure, and build trust to build a robust safety culture.

Weintraub K. USA Today. May 3, 2023.

The semi-annual Leapfrog Hospital Safety Grades are recognized across the industry as a tool for highlighting successes and tracking gaps in safety to focus improvement efforts. This article shares one organization’s work to improve core safety activities related to medication safety, falls, infections, and hand hygiene.

Moorehead LD. Outpatient Surgery. April 5, 2023.

Retained surgical items (RSIs) are considered “never events” but continue to be a source of patient harm. This article discusses the various factors that increase risk of RSIs and strategies to prevent them, such as a consistent counting process and fostering a culture of safety that encourages speaking up and a non-punitive response to errors.

Bean M, Carbajal E. Becker's Hospital Review. March 29, 2023.

The RaDonda Vaught conviction reverberated throughout health care and marked weaknesses in systems response to errors and the clinicians who make them. This news article examines how health care organizations renewed efforts to establish and nurture a culture of safety and error reporting in service of safe patient care and learning from mistakes.

ISMP Medication Safety Alert! Acute care edition. March 23, 2023;28(6):1-4.

Medication mistakes are recognized contributors to patient harm. This article discusses medication errors that continue to occur despite established practices that, if applied, can mitigate error occurrence. Recommended areas of focus include reducing emphasis on the “Five Rights” to address system problems, enhancing medication list accuracy, and improving neuromuscular blocking agent storage.
Urgent care clinics offer services to a wide patient base that increase the complexities of medication prescribing and administration. Safety culture, process, and structural factors are discussed as avenues to increase safety in this unique ambulatory setting. The piece highlights the importance of education, rules, and storage procedures to ensure safe medication administration.

ISMP Medication Safety Alert! Acute care edition. February 23, 2023;28(4):1-4; March 9, 2023:28(5):1-4.

Drug diversion can reduce patient safety and should be addressed at a system level to reduce its occurrence and impact. Part I of this two-part series examines ways in which drug diversion can affect care teams, and outlines what to watch for to flag its occurrence at the clinician, record keeping, and medication inventory levels. Part II shares tactics to minimize controlled substance diversion, and track, document and take action when it does occur.

Bilski J. Outpatient Surgery. February 2023;16-21

The concept of just culture was challenged in a high-profile medication error resulting in criminal charges for a nurse. This dialogue shares insights on the impact of the case on nurses, their profession, and patient safety.

ISMP Medication Safety Alert! Acute care edition. February 9, 2023;28(3):1-4.

Patient safety event reporting is an established component of a learning strategy. This article explores weaknesses in siloed error reporting mechanisms and recommends analysis efforts as key to design and prioritize actions to use in tandem with reporting to result in lasting system changes and enhanced patient safety.

ISMP Medication Safety Alert! Acute care editionJanuary 26, 2023:28(2):1-4.

Look-alike and sound-alike drug names are a perpetual cause for confusion that decreases medication safety. This article discusses the results of a national survey on the importance of mixed case drug names, which found that 94% of the 298 respondents reported using mixed case drug names in their organization and that the majority of participants felt that mixed case lettering prevents drug selection events. The survey also identified new drug names for inclusion on the 2023 list revision.

R3 Report. December 20, 2022;38:1-8.

Health care inequities persist despite increasing awareness they negatively affect quality, safety, and patient centeredness. This article shares the Joint Commission strategy for embedding equity improvement into the National Patient Safety Goal initiative to increase focus on equity as a safety priority across all care environments.

ISMP Medication Safety Alert! Acute care edition. January 12, 2023;28(1):1-4.

The patient safety movement has raised awareness of the presence of multiple factors that align to result in patient harm, yet implementing processes to fully examine and change practice from that perspective is challenged. This article discusses this situation and provides recommendations to orient improvement efforts toward deeper investigation methods to identify latent contributors to care failure.

DePeau-Wilson M. MedPage Today. January 13, 2023.

The use of anesthesia in ambulatory settings presents both advantage and risk to patients and clinicians. This article discusses evidence defining these issues. It suggests that improved collaboration with anesthesiologists represents opportunities for nonoperating room anesthesia safety.

Pharmacy Practice News Special Edition. December 13, 2022: 43-54.

Medication errors continue to occur despite long-standing efforts to reduce them. This article summarizes types of errors submitted to the Institute for Safe Medication Practices reporting program in 2021. The piece discusses the medications involved, recommendations for improvement, and technologies to be employed to minimize error occurrence.

ISMP Medication Safety Alert!: Acute Care Edition. December 1, 2022;27(24):1-3.

Look-alike medications are vulnerable to wrong route and other use errors. This article examines the potential for mistaken application of ear drops into eyes. Strategies highlighted to reduce this error focus on storage, dispensing, administration, and patient education.

ISMP Medication Safety Alert! Acute care edition. November 17, 2022;27(23).

Enteral feeding tube medication delivery presents safety challenges that can cause harm. This article highlights problems with feed tube medication administration. It shares improvement recommendations that include best practice adherence, standardization, monitoring, and patient engagement.

ISMP Medication Safety Alert! Acute care edition. October 20, 2022;20(21):1-5.

Errors due to inadequate information use with intravenous smart pumps are a safety concern. This article discusses factors that contribute to medication errors and smart pumps, which include out-of-date drug libraries, omitted dose limits, and variable rate infusions. Recommendations for improvement include the creation, testing, and updating of drug libraries.

ISMP Medication Safety Alert! Acute care edition. October 6, 2022;27(20):1-5.

Patient resuscitation is a complex, distinct, team activity that can be prone to error. Pharmacists involved in codes reported concerns including errors with high-alert medications and communication gaps. Improvement recommendations focused on preparation for, actions during and post code phrases which included standardizing the practice of including pharmacists in codes, simulation, and regular debriefing.
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.

Millenson M. Forbes. September 16, 2022.

Unnecessary medication infusions indicate weaknesses in medication service processes. While no harm was noted in the case discussed, the actions by the patient’s family to initiate an examination of the incident were rebuffed, patient disrespect was demonstrated, a near miss incident report was absent, and data omissions took place. The piece discusses how these detractors from safety were all present at the hospital involved.