The PSNet Collection

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.

Input for the TeamSTEPPS Curriculum Updates.

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Rockville MD, Agency for Healthcare Quality and Research. December 7, 2021.

The TeamSTEPPS program is an established approach for improving teamwork and communication in health care. This announcement calls for feedback from healthcare teams and team members on how to update the current TeamSTEPPS training curriculum.

Safe handling of concentrated electrolyte products from outsourcing facilities during critical drug shortages.

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National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American Society of Health-System Pharmacists. May 24, 2018.

Drug shortages can necessitate hospitals to find alternative sources for important medications. This alert raises awareness of risks associated with potassium chloride use due to variations in labeling, packaging, or concentration of outsourced medications. Recommendations include use of barcode scanning and communicating with staff regarding drug shortages.

Implantable infusion pumps in the magnetic resonance (MR) environment: FDA safety communication—important safety precautions.

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MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 11, 2017.

Hazards in the magnetic resonance imaging environment can result in patient harm. This announcement raises awareness of inaccuracies and disruptions that may affect the safety of patients with implantable infusion devices who undergo an MRI exam. The statement recommends that patients inform their care team and carry an implant card with information about the implanted device to prevent these problems.

Patient safety teams recognised at BMJ awards.

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Gulland A. BMJ. 2014;348.

The Great Ormond Street Hospital Foundation NHS Trust received the 2014 Berwick Patient Safety Team Award for their project "Pursuing Zero by Building Sustainable Foundations for Safety," which applied recommendations generated in response to the Francis report. The program introduced a daily questionnaire for parents and patients about problems related to medication errors, equipment, communication, or organization of care, which was then reviewed with a nurse to immediately address concerns.

The MacArthur Fellows Program: Eric Coleman.

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MacArthur Foundation.

Dr. Eric Coleman has enhanced care transitions by developing tools and processes to improve communication and reduce readmissions. The MacArthur Foundation has selected him as a 2012 Fellow and recipient of $500,000 (often called a "genius grant").

Medication errors resulting from confusion between risperidone (Risperdal) and ropinirole (Requip).

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MedWatch Safety Alert, FDA Drug Safety Communication. Silver Spring, MD: US Food and Drug Administration; June 13, 2011.

This notice raises awareness of a two look-alike/sound-alike drugs, one an antipsychotic medication and the other a dopamine agonist.

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