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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 - 20 of 71 Results
Kakemam E, Chegini Z, Rouhi A, et al. J Nurs Manag. 2021;29:1974-1982.
Clinician burnout, characterized by emotional exhaustion, depersonalization, and decreased sense of accomplishment, can result in worse patient safety outcomes. This study explores the association of nurse burnout and self-reported occurrence of adverse events during COVID-19. Results indicate higher levels of nurse burnout were correlated with increased perception of adverse events, such as patient and family verbal abuse, medication errors, and patient and family complaints. Recommendations for decreasing burnout include access to psychosocial support and human factors approaches.
Leviatan I, Oberman B, Zimlichman E, et al. J Am Med Inform Assoc. 2021;28:1074-1080.
Human factors, such as cognitive load, are main contributors to prescribing errors. This study assessed the relationship between medication prescribing errors and a physician’s workload, successive work shifts, and prescribing experience. The researchers reviewed presumed medication errors flagged by a computerized decision support system (CDSS) in acute care settings (excluding intensive care units) and found that longer hours and less experience in prescribing specific medications increased the risk of prescribing errors.
Waterson J, Al-Jaber R, Kassab T, et al. JMIR Hum Factors. 2020;7:e20364.
Smart pumps are considered a valuable method to improve medication safety. This study used smart pump medication logs and reporting software to identify cancelled infusions and resolutions of infusions alerts to characterize near-miss infusion pump errors. The study identified a high number of lookalike-soundalike near-miss errors. Analyses indicate that incorrect medication and wrong dose selections account for approximately 22% of all cancelled infusions.
Naseralallah LM, Hussain TA, Jaam M, et al. Int J Clin Pharm. 2020;42:979-994.
Pediatric patients are particularly vulnerable to medication errors. In this systematic review, the authors evaluated the evidence on the effectiveness of clinical pharmacist interventions on medication error rates in hospitalized pediatric patients. Results of a meta-analysis found that pharmacist involvement was associated with a significant reduction in the overall rate of medication errors in this population.
Librov S, Shavit I. J Pain Res. 2020;13:1797-1802.
This retrospective study evaluated the impact of a pre-sedation checklist on serious adverse events among children treated with ketamine and propofol in a pediatric emergency department. There were significantly more serious adverse events recorded after the implementation of the checklist.  
Aghili M, Neelathahalli Kasturirangan M. JBI Evid Implement. 2021;19:21-30.
This study evaluated the impact of clinical pharmacist-led interventions on medication errors and preventable adverse drug events among patients in the ICU. The clinical pharmacist performed medication chart review, patient monitoring, and attended medical rounds in order to evaluate the appropriateness of the pharmacological treatment, identify and report drug-related issues, and provide evidence-based recommendations for the management of medication errors. When the pharmacist’s recommendations were implemented by prescribing physicians, approximately half of medication errors were intercepted before reaching the patient, resulting in fewer preventable adverse drug events.
Sim MA, Ti LK, Mujumdar S, et al. J Patient Saf. 2022;18:e189-e195.
This article describes the implementation of a hospital-wide patient safety strategy aimed at reducing hospital-wide adverse events at a single large hospital in Singapore. The strategy included establishing interdisciplinary patient safety teams to identify areas of preventable harm, determine root causes, improve departmental accountability, and leveraging simulation training. Over a 7-year period, adverse event rates decreased significantly (as did the incidence of preventable adverse events and the incidence of events resulting in permanent harm, the use of life-sustaining interventions, or death.
Almalki H, Absi A, Alghamdi A, et al. JAMA Netw Open. 2020;3.
Effective communication between patients and physicians is essential to ensuring treatment adherence and improved patient outcomes. This cross-sectional study measured agreement in treatment plan understanding between oncology patients and providers in Saudi Arabia and found that most patients (86.2%) had a suboptimal understanding of their chemotherapy treatment plan. Patients commonly did not understand the planned duration of their treatment or the important toxic effects of chemotherapy.
Aldawood F, Kazzaz Y, AlShehri A, et al. BMJ Open Qual. 2020;9.
This study reports on results of completing TeamSTEPPS training by leadership and staff in the pediatric intensive care unit (PICU) at one hospital in Saudi Arabia. The team implemented a daily safety huddle aimed at improving communication and early identification and timely resolution of patient safety issues. Over a 7-month period, 340 safety issues were addressed; the majority involved infection control and medication errors (32%), communication issues (24%) and documentation issues (17%). The authors observed that the daily huddle addressed misconceptions and misunderstandings between nursing and medical teams leading to improved care delivery.
Pourteimour S, Hemmati MalsakPak M, Jasemi M, et al. Pediatr Qual Saf. 2019;4.
This single site study examined the effect of a smartphone messenger app on nursing students’ learning about preventing medication errors in pediatric patients. Researchers concluded that such a tool can reduce medication errors and increase learning among nursing students.
Eslami K, Aletayeb F, Aletayeb SMH, et al. BMC Pediatr. 2019;19:365.
Medication errors are thought to be common in neonatal intensive care units (NICUs). This study compared the incidence of medication errors occurring in two NICUs over a three-month period. Over the study period, there were an average of 3.38 medication errors per patient and three-quarters of neonates experienced at least one error. Preterm neonates experienced medication errors significantly more often than term neonates. Errors in prescription dosage and administration were the most common errors.
Fahrni ML, Azmy MT, Usir E, et al. PLoS One. 2019;14:e0219898.
In this prospective study involving 301 older patients admitted to 3 hospitals, researchers used the STOPP and START criteria to identify inappropriate prescribing and adverse drug events. Inappropriate prescribing was detected in 59% of patients and potentially inappropriate medications in 35% of patients. The use of inappropriate medications was associated with an increased odds of an adverse drug event.
Segal G, Segev A, Brom A, et al. J Am Med Inform Assoc. 2019;26:1560-1565.
Alerts designed to prevent inappropriate prescribing of medications are frequently overridden and contribute to alert fatigue. This study describes the use of machine learning to improve the clinical relevance of medication error alerts in the inpatient setting.
Patel S, Robertson B, McConachie I. Anaesthesia. 2019;74:904-914.
Medication administration mistakes can result in serious patient harm. This review explored human factors that contribute to spinal anesthesia administration errors. The authors documented organizational, supervisory, system, and individual factors that contributed to errors. They recommend strategies to prevent such incidents, including the use of double checks and improved labeling practices.
Riskin A, Bamberger P, Erez A, et al. Jt Comm J Qual Patient Saf. 2019;45:358-367.
Prior studies have demonstrated that rude behavior undermines patient safety. This study used a smartphone application to collect reports of rudeness directed toward nurses. These data were analyzed in conjunction with the hospital's hand hygiene and medication protocol compliance data as well as adverse event reports to determine if rudeness affected these safety outcomes. Participants also reported whether rudeness incidents influenced their cognition or their teamwork. Although rudeness was associated with worse self-reported cognition and teamwork, investigators did not observe differences in reported adverse events or changes in hand hygiene or medication protocol adherence related to rudeness exposure. A past PSNet perspective discussed how organizations are seeking to rehabilitate persistently disruptive clinicians.
Hsu K-Y, DeLaurentis P, Bitan Y, et al. J Patient Saf. 2019;15:e8-e14.
Smart infusion pumps store drug safety information, but this data must be periodically updated. This study demonstrated significant delays in updating the drug information for smart infusion pumps. These delays resulted in failure to alert for two high-risk medication cases, but neither case led to patient harm.
George D, Hassali MA, Hss A-S. JMIR Hum Factors. 2018;5:e12232.
This mixed-methods study examined the usability of a mobile application for reporting medication errors at a referral hospital in Malaysia. Usability improved over each of the three cycles of testing and iterative redesign, but physician and nurse testers expressed concern about whether the safety culture supported reporting.
Mongkhon P, Ashcroft DM, Scholfield N, et al. BMJ Qual Saf. 2018;27:902-914.
This meta-analysis sought to identify the prevalence of hospital admissions attributed to nonadherence to medications. There was significant heterogeneity among the included studies. Researchers found that about 1% to 10% of hospital admissions are due to nonadherence to medications in the outpatient setting and are therefore preventable.