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.

ISMP Medication Safety Intensive.

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Institute for Safe Medication Practices. November 30-December 1, 2023, 7:30 AM - 4:30 PM (eastern).

This virtual workshop will explore tactics to ensure medication safety, including strategic planning, risk assessment, and Just Culture principles.

Curated Libraries

Value and Patient Safety

March 8, 2023

Value as an element of patient safety is emerging as an approach to prioritize and evaluate improvement actions. This library highlights resources that explore the business case for cost effective, efficient and impactful efforts to reduce medical errors.

Lessons Learned about Human Fallibility, System Design, and Justice in the Aftermath of a Fatal Medication Error.

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Institute for Safe Medication Practices and the Just Culture Company. May 6, 2022.

Organizational factors can contribute to the occurrence of patient safety events and how health systems respond to such events. This webinar highlighted lessons learned in the aftermath of a fatal medication error, and strategies to improve patient safety at the organizational level through system design and accountability.

Diversion is a Threat to Patient Safety: Adopting Best Practices.

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Institute for Safe Medication Practices. April 6, 2022.

Drug diversion can result in patient harm due to reduced medication availability, impaired clinician performance, and loss of trust. This webinar discussed the impact of drug diversion at a system level and outlined steps an organization can take to minimize this risk through workplace health strategies and stewardship programs.

Important Actions Community Pharmacists Need to Take Now to Reduce Potentially Harmful Dispensing Errors.

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Institute for Safe Medication Practices. October 26, 2021.

Community pharmacies encounter a variety of challenges to medication safety. This webinar focused on high-alert medications and discuss unreliable medication delivery methods. The session also covered vaccination errors and how to prevent them.

Enhancing Your Medication Error Reporting Program to Improve Global Medication Safety.

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Institute for Safe Medication Practices. September 15, 2020.

Medication error reporting is key to understanding failures, identifying risk and informing improvement. This webinar discussed approaches to internal reporting and challenges to reporting success.

Medication Safety During the COVID-19 Pandemic: What Have We Learned in the United States.

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Institute for Safe Medication Practices and US Food and Drug Administration Division of Drug Information. June 23, 2020.

The COVID-19 pandemic response is creating a need for care delivery adjustments that include changes in pharmacy and medication practices. This webinar discussed process alterations that have the potential to impact safe medication administration and provide context for the changes to help ensure they are effectively implemented.

Deprescribing Guidelines: Special Section on Symposium Results.

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Res Social Adm Pharm. 2019;15(6):780-810.

Appropriate deprescribing can reduce the risks associated with polypharmacy, overuse, and accidental overdose. Articles in this special section cover findings from a symposium discussing guidelines for safe discontinuation of medications and research needed to support further understanding of deprescribing practices.

Communicating Clearly About Medicines: Proceedings of a Workshop.

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National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press: 2017. ISBN: 9780309461856.

Patient health literacy is a known challenge in health care safety. This publication reports on results of a multidisciplinary workshop that explored health literacy improvement strategies and tools to enhance the clarity of labels, patient instructions, and decision aids to support safe medication use.

Pain Management and Prescription Opioid-related Harms: Exploring the State of the Evidence: Proceedings of a Workshop—in Brief.

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Forstag EH; Committee on Pain Management and Regulatory Strategies to Address Prescription Opioid Abuse; Health and Medicine Division. Washington, DC: National Academy of Science; 2016. ISBN: 9780309451901.

Efforts to ensure safe pain management in the context of the opioid epidemic have focused on prescribing behaviors and policies. This publication reports on the results of a workshop convened to explore factors that contribute to opioid overuse and to identify areas for improvement that require further research.

At the Precipice of Quality Health Care: The Role of the Toxicologist in Enhancing Patient and Medication Safety.

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J Med Toxicol. 2015;11(2):165-166, 252-273.

This special issue highlights proceedings from a conference that explored the intersection of toxicology and patient safety improvement. Articles explore how toxicologists can contribute to medication safety efforts through simulation training, collaborating with organizations such as poison control centers, and utilizing communication tools to enhance teamwork.

A Hospital Accident: Lessons Learned – A Death, A Conviction, and A Healing.

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Texas Medical Institute of Technology. June 16, 2011.

This archived webinar covered how medical errors affect both the family and provider involved, and offered recommendations for best practices following a medical error.

The Safe Use Initiative and Health Literacy: Workshop Summary.

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Vancheri C; Roundtable on Health Literacy; Institute of Medicine. Washington, DC: National Academies Press; 2010. ISBN-10: 0309159318.

This publication summarizes the content delivered at a workshop discussing the FDA's Safe Use Initiative and other medication label improvement programs.

Proceedings of a summit on preventing patient harm and death from IV medication errors.

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American Journal of Health-System Pharmacy. 2008;65.

Experts convened to discuss best practices for safe intravenous medication administration. This article reports on the results of that conference along with ways to implement the suggested practices.

AHRQ 2007 Annual Conference.

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Agency for Healthcare Research and Quality; AHRQ.

This Web site provides access to presentation materials from AHRQ's first annual conference, held in September 2007.

Standardizing Medication Labels: Confusing Patients Less, Workshop Summary.

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Hernandez LM; for Roundtable on Health Literacy, Board on Population Health and Public Health Practice, Institute of Medicine. Washington, DC: National Academies Press; 2008.

Depicting how medication labels and instructions confuse patients, this report addresses ambulatory medication safety and offers recommendations on how to standardize pharmacy labels to help prevent errors.

The "top 10" drug errors and how to prevent them.

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The author summarizes a conference session on medication safety improvement and provides insight from a variety of experts on preventing medication errors. Continuing education credit is available.

Safety in the NICU: preventing medical errors.

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Stokowski LA. Medscape Nurses. 2007.

The author discusses medical error in the neonatal intensive care unit (NICU) and the role of teamwork in achieving safety. Continuing education credit is available.

Public Meeting on Improving Patient Safety by Enhancing the Container Labeling for Parenteral Infusion Drug Products.

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Fed Reg. Nov. 28, 2006;71:68819.

The US Food and Drug Administration invited experts to comment on how labels for intravenous drugs could be designed to ensure the safe use of these medications through informed label redesign efforts.

An Introduction to the Improved FDA Prescription Drug Labeling.

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Silver Spring MD; US Food and Drug Administration: 2006.

This teleconference discussed the 2006 FDA medication package insert design program and reviewed prescription drug labeling format changes. Handouts and an audio download of the presentation are available.

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