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 66 Results

RFID tags reduce restocking errors of anesthesia medications.

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Banks MA. Specialty Pharmacy Continuum. September 15, 2023.

Radiofrequency identification (RFID) devices are being used to improve processes in the operating room and prevent errors. This article examines the use of RFID tracking to build reliability into operating room anesthesia medication refiling process. The experience at one hospital found that the RFID process reduced errors, while increasing the task completion time.

Pediatric Diagnostic Safety: State of the Science and Future Directions.

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Grubenhoff JA, Cifra CL, Marshall T, et al. Rockville, MD: Agency for Healthcare Research and Quality; September 2023. AHRQ Publication No. 23-0040-5-EF.

Unique challenges accompany efforts to study and reduce diagnostic error in children. This issue brief discusses addressing obstacles associated with testing and care access limitations that affect diagnosis across a variety of pediatric care environments. It also provides recommendations for building capacity to advance pediatric diagnostic safety. This issue brief is part of a series on diagnostic safety.

Sentinel Event Alert 67: Preserving Patient Safety After a Cyberattack.

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Jt Comm J Qual Patient Saf. 2023;49:724-729.

Cyberattacks and technology disruptions are increasing as a threat to patient safety. This alert identifies risks linked to cyberattacks. The authors discuss how organizations might be proactive in order to prevent the potential for data breaches and reduce their impact on care delivery and processes should cyberattacks occur.

Reimagining Healthcare Teams: Leveraging the Patient-Clinician-AI Triad To Improve Diagnostic Safety.

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James C, Singh K, Valley TS, et al. Rockville, MD; Agency for Healthcare Research and Quality; July 2023. AHRQ Publication No. 23-0040-4-EF.

As artificial intelligence (AI) and machine learning (ML) become established in health care, it is critical for clinicians and patients to effectively collaborate to use AI safely. This Issue Brief adds to a series of diagnostic-focused reports and presents a framework to guide patients and clinicians on working as team members when using AI and ML to make diagnostic decisions.

Final Report on Prioritization of Patient Safety Practices for a New Rapid Review or Rapid Response. Making Healthcare Safer IV Series.

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Rosen M, Dy SM, Stewart CM, et al. Making Healthcare Safer IV Series. Rockville, MD: Agency for Healthcare Research and Quality; July 2023. AHRQ Publication no. 23-EHC019-1.

Reducing preventable harm in healthcare settings remains a national priority. This report summarizes the results of the prioritization process used to identify patient safety practices meriting inclusion in the fourth installment of the Making Healthcare Safer (MHS) series (previous installments were published in 2001, 2013, and 2020). The fifteen-member Technical Expert Panel identified 27 priority patient safety practices for examination in the forthcoming report, including several practices that have not been covered in previous MHS reports (e.g., family/caregiver engagement, preventing non-ventilator associated pneumonia, supply chain disruption, high reliability, post-event communication programs).

Mitigating bias in AI at the point of care.

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Decamp M, Lindvall C. Science. 2023;381(6654):150-152.

Computerized clinical support is vulnerable to bias due to widespread health care inequalities that feed into the systems. This article discusses the need for collective effort to increase equitable application of artificial intelligence through a recognition of latent factors at the clinician, patient, and policy levels that contribute to algorithmic biases.

Taking a closer look at medication errors that involve oxytocin.

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ISMP Medication Safety Alert! Acute care edition. June 1, 2023; 28(11):1-6.

Oxytocin, which is commonly used to induce labor, has been associated with adverse events. Based on 2,073 oxytocin-related medication errors reported to one patient safety organization, the authors of this article summarize the common event types (e.g., pump misprogramming, incorrect infusion set-up, or use of incorrect drug or concentration) and highlight several recommendations to increase safe oxytocin administration.

Curated Libraries

Implementation of Patient Safety Projects Curated Library

May 4, 2023

The implementation of effective patient safety initiatives is challenging due to the complexity of the health care environment. This curated library shares resources summarizing overarching ideas and strategies that can aid in successful program execution, establishment, and sustainability.

Hospital ‘black boxes’ put surgical practices under the microscope.

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Sadick B. Wall Street Journal. March 19, 2023.

Safety information systems that track action in real time can reveal a trove of data about how teams and procedures progress. This news article describes the use of a black-box system in the operating room. Its use by hospitals in the United States is described to illustrate the value of black box data to inform learning and improvement strategies.

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.

Artificial intelligence, patient safety, and achieving the quintuple aim in anesthesiology.

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Tan JM, Cannesson MP. APSF Newsletter. 2023;38(2):1,3–4,7.

Technological advancement is a hallmark of anesthesiology safety improvement. This article discusses the opportunities that artificial intelligence (AI) represents for anesthesiologists and provides a practical framework for understanding the important relationship to be optimized between AI and perioperative care to support patient safety.

Society for Maternal-Fetal Medicine Special Statement: telemedicine in obstetrics-quality and safety considerations.

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Healy A, Davidson C, Allbert J, et al. Am J Obstet Gynecol. 2023;228:b8-b17.

The demand for, and acceptance of, telemedicine solutions to provide services has grown substantially in recent years as safety profiles for the services are being defined. This guideline examines its use in pregnancy-related care, discusses the benefits and suggests actions to ensure patient safety during these encounters such as development of appropriate metrics and methods for vital-sign monitoring.

Curated Libraries

Diagnostic Safety

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.

Curated Libraries

Medication/Drug Errors

January 14, 2022

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...

Curated Libraries

Maternal Safety

September 13, 2021

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.

FDA Safety Communication: update--robotically-assisted surgical devices in mastectomy.

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MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; August 20, 2021.

This announcement seeks to raise awareness of the potential risks associated with the use of robotic-assisted surgical devices in mastectomies or cancer-related care. Recommendations for patients who may seek to have robotically assisted surgery include asking about their surgeon's experience with these procedures and discussing benefits, risks, and alternatives regarding available treatment options with their health care provider. Suggestions for health care providers include completing specialized training on procedures they perform. A WebM&M commentary described the challenges and benefits associated with robotic surgery.

Health Information Technology for Engaging Patients in Diagnostic Decision Making in Emergency Departments.

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Mangus CW, Singh H, Mahajan P. Rockville, MD: Agency for Healthcare Research and Quality; February 2021. AHRQ Publication No. 20(21)-0040-4-EF.

Health information technology (Health IT) presents opportunities to engage patients and families in decision making. This issue brief highlights health IT tools that can close this communication gap to engage patients in diagnosis in the emergency room. This brief is part of a publication series examining diagnostic improvement across health care.

FDA alerts health care professionals to the temporary absence of warning statement on the vial caps of two neuromuscular blocking agents.

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MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration. June 2, 2020.

Neuromuscular blocking agents are high alert medications that can severely harm patients if used incorrectly. This announcement alerts clinicians to the absence of warning statements on two types of paralyzing agents, as well as to steps to minimize mistaken use.

Incorrect use of smart infusion pump in the operating room (OR) leads to milrinone overdose.

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ISMP Medication Safety Alert! Acute care edition. May 7, 2020;25(9).

Lack of familiarity with smart pumps can lead to user error and patient harm. The article describes conditions that lead to a programing mistake. It suggests enhanced “hands on” education, improved medication labeling, required engagement with drug libraries when programing pumps and assessed equipment competency as actions to mitigate similar incident occurrence.

Do you know what doses are being programmed in the OR? Make it an expectation to use smart infusion pumps with DERS.

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ISMP Medication Safety Alert! Acute care edition!. 2020;25:1-5.

Dose error-reduction systems (DERS) are standard functions in smart pumps. While they are designed to recognize dosing and programming errors, it has been observed that DERS are not fully utilized in operating rooms (OR). This article shares recommendations for addressing this medication safety gap including working with anesthesia providers and OR team members to establish use of DERS as an expected practice.

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