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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 - 18 of 18 Results
Sutherland A, Jones MD, Howlett M, et al. Drug Saf. 2022;45:881-889.
Intravenous (IV) medication smart pumps can improve medication administration, but usability issues can compromise safety. This article outlines strategic recommendations regarding the implementation of smart pump technology to improve patient safety. Recommendations include standardization of infusion concentrations, improving drug libraries using a human-centered approach, and increasing stakeholder engagement.

Szalavitz M. Wired Magazine. August 11, 2021. 

The opioid epidemic has contributed to uncertainties for pain management patients that result in harm. This article discusses how an endometriosis patient was unable to get prescriptions to manage her pain due to misinformation generated through screening tools designed to identify opioid misuse and inform prescribing decisions.

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.
Philadelphia, PA: Pew Charitable Trusts and Institute for Behavioral Health, Heller School for Social Policy and Management at Brandeis University; 2016.
Drug monitoring systems can help track opioid prescription activity to mitigate the opioid crisis. Highlighting the value of these state-sponsored programs to reduce overprescribing, this report recommends eight practices to optimize the use of prescription drug monitoring programs and review state adoption of them. The strategies include simplifying the prescriber enrollment process and integrating health information technology.
Sharif I, Tse J. Pediatrics. 2010;125:960-5.
Misunderstanding prescription drug labels is a recognized source of errors in ambulatory care. Low health literacy places patients at higher risk, and language barriers may also contribute to preventable medication errors, as illustrated vividly in an AHRQ WebM&M commentary. A prior study found that translated drug labels are available in many pharmacies, but this study found that Spanish-language labels generated by commercial translation systems are disturbingly inaccurate. Half of the labels contained at least one error, and the authors document examples of incomplete or inaccurate translations that could lead to serious patient harm (for example, "once a day" mistranslated as "eleven times per day"). A prior study also found that Spanish-speaking patients may be at higher risk of experiencing errors while hospitalized.