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 4207 Results

Untenable expectations: nurses' work in the context of medication administration, error, and the organization.

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Hawkins SF, Morse JM. Glob Qual Nurs Res. 2022;9:233339362211317.

Medication administration is a complex set of tasks completed many times per day for hospitalized patients. This study captures the turbulence of nursing work, the nursing environment, and how that impacts patient safety. The results suggest organizations should re-evaluate current attempts at improving medication administration safety and include nurses in identifying new solutions.

Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts.

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WebM&M Case February 1, 2023

A 38-year-old man with end-stage renal disease (ESRD) on chronic hemodialysis was admitted for nonhealing, infected lower leg wounds and underwent a below-knee amputation. He suffered from postoperative pain at the operative stump and was treated for four days with regional nerve blocks, as well as gabapentin, intermittent intravenous hydromorphone (which was transitioned to oral oxycodone) and oral hydromorphone.

Latent and active failures perfectly align to allow a preventable adverse event to reach a patient.

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ISMP Medication Safety Alert! Acute care edition. January 12, 2023;28(1):1-4.

The patient safety movement has raised awareness of the presence of multiple factors that align to result in patient harm, yet implementing processes to fully examine and change practice from that perspective is challenged. This article discusses this situation and provides recommendations to orient improvement efforts toward deeper investigation methods to identify latent contributors to care failure.

Improving administration and documentation of enteral nutrition support therapy in a Veteran Affairs health care system: use of medication administration record and bar code scanning technology.

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Chew MM, Rivas S, Chesser M, et al. J Patient Saf. 2023;19:23-28.

Provision of enteral nutrition (EN) is a specialized process requiring careful interdisciplinary teamwork. After discovering significant issues with ordering, administration, and documentation of EN, this health system updated its workflows to improve safety. EN therapies were added to the electronic medication administration record (MAR) and the barcoding system was updated. After one year, all EN orders were barcode scanned and nearly all were documented as given or included a reason why they were not given.

Toward the translation of systems thinking methods in patient safety practice: assessing the validity of Net-HARMS and AcciMap.

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Salmon PM, King B, Hulme A, et al. Safety Sci. 2022;159:106003.

Organizations are encouraged to proactively identify patient safety risks and learn from failures. This article describes validity testing of systems-thinking risk assessment (Net-HARMS) to identify risks associated with patient medication administration and an accident analysis method (AcciMap) to analyze a medication administration error.

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.

Long-Term Trends of Psychotropic Drug Use in Nursing Homes.

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Grimm CA. Washington DC: Office of the Inspector General; Nov 2022. Report no. OEI-07-20-00500.

Misdiagnosis can result in inappropriate medication use. This report examined the overuse of antipsychotics in nursing homes and resident harms. These recommendations from the U.S. Department of Health and Human Services Office of the Inspector General include heightened evaluation and oversight of medication use and better documentation of diagnosis with medication orders as avenues for improvement.

Hospital-Acquired Diabetic Ketoacidosis.

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WebM&M Case February 1, 2023

This WebM&M highlights two cases of hospital-acquired diabetic ketoacidosis (DKA) in patients with type 1 diabetes. The commentary discusses the role of the inpatient glycemic team to assist with diabetes management, the importance of medication reconciliation in the emergency department (ED) for high-risk patients on insulin, and strategies to empower patients and caregivers to speak up about medication safety.

FDA and ISMP Lists of Look-Alike Drug Names With Recommended Tall Man Letters.

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Food and Drug Administration and Institute for Safe Medication Practices. Plymouth Meeting, PA; Institute for Safe Medication Practices; January 2023.

Mistakes associated with look-alike medication names are a safety concern in health care. Tall man, or mixed case, lettering is one recommended strategy to reduce confusion associated with similarities in drug names. This list includes medications recognized by clinicians and professional organizations as those suited for the application of mixed case lettering to make their use safer.

The safety of inpatient health care.

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Bates DW, Levine DM, Salmasian H, et al. New Engl J Med. 2023;388:142-153.

An accurate understanding of the frequency, severity, and preventability of adverse events is required to effectively improve patient safety. This study included review of more than 2,800 inpatient records from 11 American hospitals with nearly one quarter having at least one preventable or not preventable adverse event. Overall, approximately 7% of all admissions included at least one preventable event and 1% had a severity level of serious or higher.

Exploring nursing-sensitive events in home healthcare: a national multicenter cohort study using a trigger tool.

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Nilsson L, Lindblad M, Johansson N, et al. Int J Nurs Stud. 2022;138:104434.

Nurse-sensitive outcomes are important indicators of nursing safety. In this retrospective study of 600 patient records from ten Swedish home healthcare organizations, researchers found that 74% of patient safety incidents were classified as nursing-sensitive and that the majority of those events were preventable. The most common types of nursing-sensitive events were falls, pressure injuries, healthcare-associated infections, and incidents related to medication management.

Improving communication from hospital to skilled nursing facility through standardized hand-off: a quality improvement project.

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Baluyot A, McNeill C, Wiers S. Patient Safety. 2022;4:18-25.

Transitions from hospital to skilled nursing facilities (SNF) remain a patient safety challenge. This quality improvement (QI) project included development of a structured handoff tool to decrease the wait time for receipt of controlled medications and intravenous (IV) antibiotics and time to medication administration. The project demonstrated significant improvements in both aims and can be replicated in other SNFs.

Incidence and characteristics of adverse events in paediatric inpatient care: a systematic review and meta-analysis.

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Dillner P, Eggenschwiler LC, Rutjes AWS, et al. BMJ Qual Saf. 2022;Epub Dec 26.

Retrospective error detection methods, such as trigger tools, are widely used to uncover the incidence and characteristics of adverse events (AE) in hospitalized children. This review sought AEs identified by three trigger tools: Global Trigger Tool (GTT), the Trigger Tool (TT) or the Harvard Medical Practice Study (HMPS) method. Results from the trigger tools were widely variable, similar to an earlier review in adult acute care, and suggest the need for strengthening reporting standards.

A scoping review of non-professional medication practices and medication safety outcomes during public health emergencies.

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Kelly D, Koay A, Mineva G, et al. Public Health. 2022;214:50-60.

Natural disasters and other public health emergencies (PHE), such as the COVID-19 pandemic, can dramatically change the delivery of healthcare. This scoping review identified considerable research examining the relationship between public health emergencies and disruptions to personal medication practices (e.g., self-altering medication regimens, access barriers, changing prescribing providers) and subsequent medication-related harm.

Introducing ISMP’s New Targeted Medication Safety Best Practices for Community Pharmacy: 2023-2024.

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Institute for Safe Medication Practices. January 31, 2023, 1:00-2:00 PM (eastern).

A variety of factors can decrease the safety of community pharmacy practice such as production pressure and fatigue. This webinar will discuss a new set of best practices for community pharmacy to address common problems that reach patients and cause harm.

Interventions to increase patient safety in long-term care facilities-umbrella review.

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Świtalski J, Wnuk K, Tatara T, et al. Int J Environ Res Public Health. 2022;19:15354.

Improving patient safety in long-term care facilities is an ongoing challenge. This systematic review identified three types of interventions that can improve safety in long-term care facilities – (1) promoting safety culture, (2) reducing occupational stress and burnout, and (3) increasing medication safety.

Self-reported gaps in care coordination and preventable adverse outcomes among older adults receiving home health care.

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Sterling MR, Lau J, Rajan M, et al. J Am Geriatr Soc. 2022;Epub Dec 5.

Home healthcare is common among older adults, who are often vulnerable to patient safety events due to factors such as medical complexity. This cross-sectional study of 4,296 Medicare patients examined the relationship between receipt of home healthcare services, perceived gaps in care coordination, and preventable adverse outcomes. The researchers found that home healthcare was not associated with self-reported gaps in care coordination, but was associated with increases in self-reported preventable drug-drug interactions (but not ED visits or hospital admissions).

Medication use evaluation of high-dose long-term opioid de-prescribing in multiple Veterans Affairs medical centers.

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Barrett AK, Sandbrink F, Mardian A, et al. J Gen Intern Med. 2022;37:4037-4046.

Opioid medication use is associated with an increased risk of adverse events; however research has shown sudden discontinuation of opioids is also associated with adverse events such as withdrawal and hospitalization. This before and after study evaluated the impact of the VA’s Opioid Safety Initiative (OSI) on characteristics and prescribing practices. Results indicate that length of tapering period increased, and mortality risk decreased following OSI implementation.

Short- and long-term effects of an electronic medication management system on paediatric prescribing errors.

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Westbrook JI, Li L, Raban MZ, et al. NPJ Digit Med. 2022;5:179.

Pediatric patients are particularly vulnerable to medication errors. This cluster randomized controlled trial examined the short- and long-term impacts of an electronic medication management (eMM) system implemented at one pediatric referral hospital in Australia. Findings suggest that eMM implementation did not reduce medication errors in the first 70 days of use, but researchers observed a decrease in medication errors one year after implementation, suggesting long-term benefits.

Patient safety performance: reversing recent declines through shared profession-wide system-level solutions.

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James BC, Savitz L, Fairbanks RJ, et al. NEJM Catalyst. Epub Dec 12, 2022.

The COVID-19 pandemic revealed fractures in health care systems worldwide. The authors advocate for enhanced use of systems-focused and organization-centric strategies to improve patient safety through universal application of best practices.

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