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 23 Results

Position Statement on Criminalization of Medical Error and Call for Action to Prevent Patient Harm from Error.

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Cooper J, Thomas BJ, Rebello E, et al for the APSF Criminalization of Error Task Force. APSF Newsletter. October 2022; 37(3):80-81

Criminalizing human error can deter the transparency necessary to learn from incidents and improve health care. This position statement articulates the importance of avoiding the criminal prosecution to mistakes to instead focus on system failures to prevent conditions that permit errors to harm patients.

When medical error becomes personal, activism becomes painful.

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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.

New Covid boosters look a lot like the old ones. Doctors worry that could lead to errors.

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Lovelace Jr, B. NBC News. September 7, 2022.

Look-alike sound-alike packaging is a known risk factor in medication errors. This news story discusses how a questionable design decision to use similar cap colors for the latest COVID boosters creates potential for administration errors.

A widow’s mission to change NC dental sedation rules.

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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.

Preventing home medication administration errors.

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Yin HS, Neuspiel DR, Paul IM, et al. Pediatrics. 2021;148:e2021054666.

Children with complex home care needs are vulnerable to medication errors. This guideline suggests strategies to enhance medication safety at home that include focusing on health literacy, prescriber actions, dosing tool appropriateness, communication, and training of caregivers.

Her husband died by suicide. She sued his pain doctors—a rare challenge over an opioid dose reduction.

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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.

Phony diagnoses hide high rates of drugging at nursing homes.

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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.

The pain was unbearable. So why did doctors turn her away?

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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.

A tragic death shows how ERs fail patients who struggle with addiction.

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Pattani A. NPR Shots. July 14, 2021.

Patients with substance abuse disorders face challenges to safe, effective care. This news story highlights how pressures associated with access and cost affect identification of these vulnerable patients and their ability to receive treatment after they arrive at an emergency room.

Addiction treatment providers in Pa. face little state scrutiny despite harm to clients.

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Pattani A, Mahon E. Kaiser Health News. April 30, 2021.

Systemic oversight weaknesses and lack of accountability undermine treatment effectiveness and safety. This article describes failures in addiction treatment that contributed to harm for vulnerable patients seeking help.

Drug error at Eskenazi Hospital killed prominent cancer researcher. Here's how it happened.

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Evans T. Indianapolis Star. October 30, 2020.

Fentanyl is a high-alert medication that can be fatal if administered inappropriately. This news story illustrates how a cascade of actions including infusion pump misuse, alarm fatigue, and unintentional blindness contributed to failure.

Investigation into Management of Venous Thromboembolism Risk in Patients Following Thrombolysis for an Acute Stroke.

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Farnborough, UK; Healthcare Safety Investigation Branch. October 13, 2020

Errors of omission in routine care can result in patient harm. This report discusses factors contributing to a pulmonary embolism in a recovering stroke patient acerbated by a lack of intended but omitted venous thromboembolism or VTE preventative care. The system improvement recommendations drawn from the incident analysis include that the UK National Health Service develop a standardized approach to VTE risk assessment and broad-based training to enable a cross-section of clinicians to use VTE prevention devices as required.

Some health workers suffering from addiction steal drugs meant for patients.

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Mann B. All Things Considered. National Public Radio. October 5, 2020.

Clinicians are susceptible for medication misuse due to stress, fatigue, or arrogance. This news article discusses how drug diversion should signal behaviors that can harm patients, the clinicians themselves, and the organizations they work for. Reporting gaps contribute to the perpetuation of the problem.

Patient Safety

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Organisation for Economic Co-operation and Development.

Organizations worldwide are focusing efforts on reducing the conditions that contribute to medical error. This website provides a collection of reports and other resources that cover activities and concerns of the 37 member countries active in the organization to address universal challenges to patient safety.

The risks of the prescribing cascade.

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Brody JE. New York Times. 2020.

Inappropriate care activities can cascade to significantly impact patient safety. This article shares how medication side effects can be misdiagnosed to perpetuate harm in older patients rather than getting to the root of the care concerns.

Two pandemics, same story: the potentially dangerous overuse of antibiotics and 'the road to medical hell'.

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Fauber J, Chen D. Milwaukee Journal Sentinel. August 31, 2020.

Antibiotic overuse is a long-standing safety concern due to the potential global public health impact of the practice in supporting drug-resistant bacteria. This news article discusses the overprescribing of antibiotics in context of viral disease pandemics.

Care Compare.

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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.

Special report: COVID deepens the other opioid crisis - a shortage of hospital painkillers.

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Girion L, Levine D, Respaut R. Reuters. 2020;June 9.

The COVID-19 pandemic has disrupted the supply of protective equipment, medical devices and medications. This article discusses how economics contribute to drug shortages and highlights the specific impact on access to the opioids essential for providing safe care for hospitalized patients with COVID-19.

There is a vulnerable group we must not leave behind in our response to COVID-19: people who are dependent on illicit drugs.

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Guirguis A. The Pharmaceutical Journal. 2020;304.

Users of illicit substances are vulnerable to a variety of health concerns. This article discusses how the COVID-19 pandemic places illicit drug users at increased risk for COVID-19 due to their predisposition to infection and social contact; how disruptions to illicit drug supply chains increase risk for overdose due to drug substitution and; the impact of missing out on drug treatment services. The piece highlights the role of pharmacists in keeping this marginalized patient population safe.

Addiction is ‘A disease of isolation’ — so pandemic puts recovery at risk.

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Bebinger M. Kaiser Health News. March 30, 2020.

In-person counseling is an important tool to keep patients in recovery safe. This story shares concerns stemming from limitations on group gatherings as a proactive COVID-19 reduction strategy. The isolation being encouraged to prevent the spread of COVID-19 may have the unintended consequence of resulting in harm in this vulnerable patient population.

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