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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 - 5 of 5 Results
WebM&M Case October 27, 2021

A 78-year-old woman with macular degeneration presented for a pars plana vitrectomy (PPV) under monitored anesthesia care (MAC) with an eye block. At this particular hospital, eye cases under MAC are typically performed with an eye block by the surgeon after the anesthesiologist has administered some short-acting sedation, commonly with remifentanil. On this day, there was a shortage of premixed remifentanil and the resident – who was unfamiliar with the process of drug dilution – incorrectly diluted the remifentanil solution.

Bickham P, Golembiewski J, Meyer T, et al. Am J Health Syst Pharm. 2019;76:903-820.
Pharmacists working with surgical teams bring distinct safety context, expertise, and process awareness to perioperative care. These guidelines outline how pharmacists can help reduce medication errors before, during, and after surgery. Perioperative pharmacists can enhance communication, medication histories, and process reliability.
Group S and P in LS. Br J Surg. 2015;102:1204-12.
This controlled study evaluated the effect of a protocolled pharmacist intervention—which included medication reconciliation and regular medication review—on medication errors in elective surgery patients. There was no difference in the incidence of adverse drug events compared to patients receiving usual care.
WebM&M Case May 1, 2004
To achieve tight glucose control, a hospitalized diabetes patient is placed on an insulin drip. Prior to minor surgery, he is made NPO and becomes severely hypoglycemic.