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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 - 17 of 17 Results
Bijok B, Jaulin F, Picard J, et al. Anaesth Crit Care Pain Med. 2023;42:101262.
Human factors influence how humans and systems interact to make processes more reliable or more error-prone during both normal and unexpected circumstances. This guideline provides recommendations centered on elements of communication, the organization, the work environment, and training to guide the consideration of human factors in improvement actions during critical anesthesia or intensive care situations.
Curated Libraries
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.

ISMP Medication Safety Alert! Acute care edition. October 6, 2022;27(20):1-5.

Patient resuscitation is a complex, distinct, team activity that can be prone to error. Pharmacists involved in codes reported concerns including errors with high-alert medications and communication gaps. Improvement recommendations focused on preparation for, actions during and post code phrases which included standardizing the practice of including pharmacists in codes, simulation, and regular debriefing.
Curated Libraries
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...
Kelley-Quon LI, Kirkpatrick MG, Ricca RL, et al. JAMA Surg. 2021;156:76.
Opioid misuse is an urgent patient safety issue, including postsurgical opioid misuse among pediatric patients. Based on the systematic review, a multidisciplinary group of health care and opioid stewardship experts proposes evidence-based opioid prescribing guidelines for children who need surgery. Endorsed guideline statements highlight three primary themes for perioperative pain management in children: (1) health care professionals must recognize the risks of pediatric opioid misuse, (2) use non-opioid pain relief, and (3) pre- and post-operative education for patients and families regarding pain management and safe opioid use.

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.  

Farnborough, UK; Healthcare Safety Investigation Branch: April 2019.

Wrong route medication administration is a never event. This report examined the context, organizational and human factors that contributed to the accidental intravenous administration of an oral solution into a pediatric patient. Safety recommendations include medication safety training, standardized administration processes, and elevation of the medication safety officer role. 
Grant M. AARP The Magazine. September/October 2010;53:48-51,90-91.
This article highlights how a medication error inspired Dennis Quaid to promote patient safety and chronicles his efforts to reduce harm in health care.
Gardner E.
This article describes how one health system markedly improved its quality and safety by applying a safety technique used in the nuclear power industry.
Hospitals & health networks. 2006;80:6 p. following 48, 2.
The authors discuss the kinds of errors that occur in emergency departments and outline processes for minimizing their occurrence.