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.
Clark J, Fera T, Fortier CR, et al. Am J Health Syst Pharm. 2022;79:2279-2306.
Drug diversion is a system issue that has the potential to disrupt patient access to safe, reliable medications and result in harm. These guidelines offer a structured approach for organizations to develop and implement drug diversion prevention efforts. The strategies submitted focus on foundational, organizational, and individual prevention actions that target risk points across the medication use process such as storage, prescribing, and waste disposal.
Atallah F, Hamm RF, Davidson CM, et al. Am J Obstet Gynecol. 2022;227:b2-b10.
The reduction of cognitive bias is generating increased interest as a diagnostic error reduction strategy. This statement introduces the concept of cognitive bias and discusses methods to manage the presence of bias in obstetrics such as debiasing training and teamwork.
Yin HS, Neuspiel DR, Paul IM, et al. Pediatrics. 2021;148:e2021054666.
Children with complex home care needs are vulnerable to medication errors. This guideline suggests strategies to enhance medication safety at home that include focusing on health literacy, prescriber actions, dosing tool appropriateness, communication, and training of caregivers.
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...
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, collaborative initiatives, teamwork, and trigger tools.
Farooqi OA, Bruhn WE, Lecholop MK, et al. Int J Oral Maxillofac Surg. 2020;49:397-402.
The over-prescribing of opioids is a recognized contributor to patient harm. This multidisciplinary panel developed six recommendations to manage pain after dental procedures while reducing harm to patients:
(1) Offer alternatives to opioids after dental surgery to interested patients when clinically appropriate.
(2) Avoid prescribing opioids after dental surgery if pain is comfortably management with over-the-counter medication.
(3) Advise patients about non-pharmacological therapies (e.g., cold, heat, distraction).
(4) Teach patients to maximize non-narcotic (over the counter) pain medication with scheduled dosing unless contraindicated.
(5) Engage in shared decision-making with patients.
(6) Consider factors such as medical contraindications, risk for addiction, and risk aversion when prescribing opioids.
Trent M, Dooley DG, Dougé J, et al. Pediatrics. 2019;144:e20191765.
Children and adolescents are particularly vulnerable to systemic weaknesses in health care. This guidance examines the impact of racism and implicit biases on pediatric patients. The policy summarizes the evidence on institutionalized racism and health to motivate the adoption of strategies to reduce that impact at the system and organizational level.
Radiology ES of, Societies EF of R. Insights Imaging. 2019;10:45.
Numerous factors affect safe imaging practice, including potential harms associated with radiation, staffing demands, and patient physical and psychological well-being. This policy statement provides multidisciplinary insights on safety themes in radiology that go beyond the core concern of inappropriate radiation exposure. The authors recommend tactics to reduce the risks related to data protection, service environment, teamwork, burnout, and training.
Rathore MH, Jackson MA, AAP Committee on Infections Diseases. Pediatrics. 2017;140(5):e20172857.
Patient safety in the ambulatory environment has received less attention than hospital settings. This guideline provides recommendations to reduce transmission of infectious agents in pediatric ambulatory care, such as policy review and development, education for personnel, and hand hygiene precautions.
Dowell D, Haegerich TM, Chou R. MMWR Recomm Rep. 2016;65:1-49.
Opioid pain medications carry high risk for adverse drug events and misuse. Due to climbing rates of opioid use and associated adverse events, the Centers for Disease Control and Prevention released new guidelines for prescribing opioid medications for chronic pain. These guidelines do not apply to patients receiving cancer treatment, palliative care, or end-of-life care. The authors recommend using opioids for chronic pain only if nonopioid medications and nonpharmacologic approaches to chronic pain are not effective and prescribing immediate-release instead of long-acting medications. For acute pain, they recommend limiting duration of therapy, stating that more than 1 week of medications should rarely be needed. The guidelines also suggest minimizing concurrent use of opioids and other sedating medications and dispensing naloxone to prevent overdoses. A previous WebM&M commentary describes an adverse event related to opioids.
The guidelines were updated in 2022.
Buxton JA, Babbitt RM, Clegg CA, et al. Am J Health-Syst Pharm. 2015;72:1221-1236.
Ambulatory pharmacy service is provided in various settings, including communities, skilled nursing facilities, and patient-centered medical care homes. Elements related to safety in this environment include leadership, patient care, distribution, and facility characteristics. This American Society of Health-System Pharmacists guideline reviews eight standards that can be adapted to support safe medication delivery in a wide range of ambulatory settings.
Mueller BU, Neuspiel DR, Fisher ERS, et al. Pediatrics. 2019;143:e20183649.
This updated policy statement from the American Academy of Pediatrics reviews the epidemiology of medical errors in children, examines unique issues in safety for pediatric patients, and discusses specific approaches to improving safety in pediatrics. The article emphasizes the responsibility of pediatricians to be familiar with patient safety concepts and techniques, and the importance of establishing a culture of safety in both inpatient and outpatient settings. The article concludes with a series of specific recommendations for advancing the science of patient safety within the field of pediatrics.
Snow V, Beck D, Budnitz T, et al. J Gen Intern Med. 2009;24:971-976.
This policy statement describes ten principles developed to address quality gaps in transitions of care between inpatient and outpatient settings. Recommendations include coordinating clinicians, having a transition record, standardizing communication formats, and using evidence-based metrics to monitor outcomes.
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