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 35 Results

A deadly epidural, delivered by a doctor with a history of mistakes.

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Goldstein J. New York Times. January 23, 2023.

Active errors are evident when they occur, yet systemic weaknesses, if not addressed, allow them to repeat. This story examines poor epidural methods of one clinician that coincided with lack of organizational practitioner monitoring, unequitable maternal care for black women and clinician COVID fatigue to contribute to patient death.

Walgreens will stop judging its pharmacy staffers by how fast they work.

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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.

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.

At US hospitals, a drug mix-up is just a few keystrokes away.

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Kelman B. Kaiser Health News. April 29, 2022.

Technological solutions harbor unique risks that can result in patient harm. This article shares a response to reports of automated dispensing cabinet (ADC) menu selection limitations that contribute to mistakes. The piece suggests the implementation of a 5-letter search requirement prior to removing a medication from an ADC. It provides an update on industry response to this forcing function recommendation.

As a nurse faces prison for a deadly error, her colleagues worry: could I be next?

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Kelman B. Kaiser Health News. March 22, 2022

Criminalization of medical mistakes typifies the blame-focused approach patient safety leaders have worked to reduce in health care. This article covers a high-profile case of medication error involving an automated dispensing system that is ubiquitous in health care.

Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, WA.

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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.

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.

Survey by Ohio regulator shows stress, fatigue among pharmacists at chain stores.

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Kaplan A. NBC News. April 21, 2021.

Pharmacies are high-pressure environments generating conditions that undermine safety. This story highlights working conditions in chain pharmacies that cause concerns for pharmacists in their ability to prepare and dispense medications safely due to lack of appropriate staffing and time to do their jobs.

Fourth Cause Campaign.

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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.

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.

Investigation into the Role of Clinical Pharmacy Services in Helping to Identify and Reduce High-risk Prescribing Errors in Hospital.

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Farnborough, UK: Healthcare Safety Investigation Branch; September 24, 2020.

Unit-based pharmacy services help to mitigate and catch medication errors. This report highlights a case of a medication error death and describes how embedding clinical pharmacy services could have prevented this incident. The report provides system level recommendations to enhance this service including defining the role of clinical pharmacy teams and prioritizing the tactic as an important improvement strategy.

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