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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

Kaplan A. NBC News. October 27, 2022. 

Suboptimal working conditions are a known contributor to errors in retail pharmacies. This news article discusses how one major pharmacy chain will adjust their staff quality metrics to eliminate timing as a performance measure in the interest of reducing pharmacist and staff burnout and fulfilment errors.

Millenson M. Forbes. September 16, 2022.

Unnecessary medication infusions indicate weaknesses in medication service processes. While no harm was noted in the case discussed, the actions by the patient’s family to initiate an examination of the incident were rebuffed, patient disrespect was demonstrated, a near miss incident report was absent, and data omissions took place. The piece discusses how these detractors from safety were all present at the hospital involved.

Washington, DC: VA Office of Inspector General; March 17, 2022.

Electronic health record (EHR) implementation failures cause major disruptions to care delivery that can result in inefficiencies, misinformation, and unsafe care. This three-part investigation examines the impact of the new United States Veterans Affairs EHR system problems on medication management, care coordination, and problem reporting and resolution at one facility.

Blythe A. NC Health News. March 10, 2022

Patient harm in dentistry is receiving increased attention and scrutiny. This story covers a medication incident and the lack of safety support that contributed to the death of a patient receiving oral surgery. It discusses the response of the patient’s family and their work to change regulations for dental sedation.

Joseph A. STAT. November 22, 2021

The opioid epidemic has put regulatory and professional pressures on the tapering of pain medications that have had unintended consequences for patients resulting in harm. This news story discusses how one family used legal means to address systemic gaps and clinical missteps that resulted in patient suicide due to lack of appropriate pain control.

Thomas K, Gebeloff R, Silver-Greenberg J. New York Times. September 11, 2021.

Nursing home medication misuse is a contributor to resident harm. This story highlights system influences such as staffing shortages, reporting failures and normalization of prescribing behaviors that coincide with the misuse of antipsychotic medications and overdiagnosis of schizophrenia.

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.

American Society of Pharmacovigilance.

Adverse drug events (ADEs) are common and contribute to patient harm. This campaign provides materials to raise general awareness of the impact of ADEs on care, hospital admissions, and costs.

Centers for Medicare and Medicaid Services.

The Centers for Medicare & Medicaid Services (CMS) support transparency through the provision of publicly available information on the quality of health care service in the United States. This portal enables access to comparative quality and safety data from doctors & clinicians, hospital, nursing home, home health, hospice, inpatient rehabilitation facilities, long-term care hospitals, and dialysis facilities to support informed consumer health care provider selection activities.

Gabler E. New York Times. February 23, 2020.

Response to reported safety concerns is a primary indicator of an organizational commitment to reducing and learning from errors. This news story discusses one retail pharmacy chain's lack of transparency regarding work conditions contributing to fulfillment pressures and errors.

Clark C. MedPage Today. February 10, 2020. 

It is an institutional responsibility to monitor physicians exhibiting performance issues that put patients into unsafe situations. This news story highlights one hospital system’s lack of action and policy adherence that failed to appropriately manage a physician with known substance abuse issues. 
Gabler E. New York Times. 2020;Jan 31.
Pharmacists are instrumental to safe medication use in the ambulatory setting. This news story discusses factors in retail pharmacy environment that degrade pharmacists’ ability to safely practice, which include production pressure, required multitasking, and distraction. Strategies highlighted to mitigate the problem that have been inconsistently applied include scheduled breaks and staff supervision limits.
Ornstein C. Los Angeles Times. September 16, 2014.
This article discusses one couple's decision to hold a pharmaceutical company legally accountable for package and label designs they believe contributed to the heparin overdose of their twin infants.