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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 20 Results
Hunter J, Porter M, Williams B. Australas Emerg Care. 2022;Epub Aug 29.
Situational awareness (SA) requires recognizing situations, interpreting them, and predicting how the situation may unfold in the future. Paramedics and emergency medical technicians (EMT) participated in a video simulation to assess their SA at each of the three stages. Quantitative results indicated the providers were not situationally aware during the simulation.
Bosson N, Kaji AH, Gausche-Hill M. Prehosp Emerg Care. 2022;26:492-502.
Pediatric medication administration in prehospital care is challenging due to the need to obtain an accurate weight and calculate dosing. The Los Angeles County emergency medical services implemented a Medical Control Guideline (MCG) to eliminate the need to calculate the dose of a commonly administered medication. Following implementation of the MCG, dosing errors decreased from 18.5% to 14.1% in pediatric prehospital care.
Arditi L. Peoples Public Radio. December 3, 2019.
Emergency medical services are often provided under chaotic circumstances that may contribute to failure. This story highlights a series of esophageal intubation errors and efforts to minimize this “never event” across the state of Rhode Island. Improvement strategies discussed include practice restrictions for EMT personnel and use of less invasive, less risky processes to provide oxygen as an alternative to intubation, which may reduce esophageal intubation errors
Hoyle JD, Ekblad G, Hover T, et al. Prehosp Emerg Care. 2020;24:204-213.
Emergency medical technicians (EMTs) often make dosing errors when administering medication to pediatric patients. This study found that in simulations, Michigan's state-wide pediatric dosing reference system reduced but did not eliminate prehospital provider medication mistakes. A PSNet perspective further explores prehospital patient safety.
Erich J.
Air transport service combines risks associated with both aviation and prehospital trauma care. This article discusses the role of human factors in this fast-paced care environment. The author encourages efforts to reduce risks through policy change, purchasing the latest safety equipment, and empowering staff to decline calls when conditions are unsafe.
Misasi P, Keebler JR. Ther Adv Drug Saf. 2019;10:2042098618821916.
This pre–post study reports a decline in medication error rates in prehospital emergency services following implementation of a human factors engineering approach. The providers implemented a team-based cross-check process using standardized communication for high-risk medications and found a significant reduction in medication errors.
Hoyle JD, Sleight D, Henry R, et al. Prehosp Emerg Care. 2016;20:117-124.
Medication errors are common in pediatric patients who require care from emergency medical services. This study found that most paramedics had limited experience and comfort in administering medications to children. Investigators identified several remediable barriers to improving medication safety in this setting.
Irving, TX: American College of Emergency Physicians; 2014.
This guidance recognizes risks associated with emergency medical services and provides recommendations to support the implementation of a safety culture in this setting.
Vilensky D, MacDonald RD. Prehosp Emerg Care. 2011;15:39-43.
This study analyzed communication errors during call bookings for air medical transport and found both human and process-driven root causes. Examples of major errors identified were commissions of allergies to medications and omissions of intubations from records.
Barishansky RM, Glick DE. EMS magazine. 2009;38:43-7.
This article explains the elements of preparing policies and procedures for reportable incidents in emergency medical services.
Fairbanks RJ, Crittenden CN, O’Gara KG, et al. Academic Emergency Medicine. 2008;15.
This study used focus groups, in-depth interviews, and event reporting methods to conclude that Emergency Medical Services (EMS) providers are concerned about existing system issues that require improvement strategies, and about the safety culture in which they work.