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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 35 Results
Berdot S, Vilfaillot A, Bézie Y, et al. BMC Nurs. 2021;20:153.
Interruptions have been identified as a common source of medication errors. In this study of the effectiveness of a “do not interrupt” vest worn by nurses from medication preparation to administration, neither medication administration error or interruption rates improved.
Keers RN, Plácido M, Bennett K, et al. PLoS One. 2018;13:e0206233.
This interview study used a human factors method, the critical incident technique, to identify underlying factors in medication administration errors in a mental health inpatient facility. The team identified multiple interconnected vulnerabilities, including inadequate staffing, interruptions, and communication challenges. The findings underscore the persistence of widely documented medication safety administration concerns.
WebM&M Case August 1, 2017
A 2-month-old boy brought in for a well-child visit was ordered the appropriate vaccinations, which included a combination vaccine for DTaP, Hib, and IPV. After administering the shots to the patient, the nurse realized she had given the DTaP vaccination alone, instead of the combination vaccine. Thus, the infant had to receive two additional injections.
Westbrook JI, Li L, Hooper TD, et al. BMJ Qual Saf. 2017;26:734-742.
This randomized controlled trial had nurses on four hospital wards wear "do not interrupt" vests during medication administration. The rate of interruptions the intervention nurses experienced was compared to the rate in four control wards that did not have nurses wear vests. Although the intervention reduced non–medication-related interruptions, nurses reported that the vests were time consuming and uncomfortable; less than half would support continuing the intervention. This study demonstrates the need to design and test sustainable interventions to improve patient safety.
Schwappach DLB, Pfeiffer Y, Taxis K. BMJ Open. 2016;6.
Chemotherapy medications can cause severe patient harm if incorrectly dosed or administered. This cross-sectional survey of oncology nurses revealed that most chemotherapy double-checking is conducted jointly rather than independently. Of note, many nurses reported being interrupted to engage in a double-check.
Bravo K, Cochran G, Barrett R. J Nurs Care Qual. 2016;31:335-41.
Medication administration errors are common and are often associated with interruptions. This study reviews data from a recent study on medication safety in critical access hospitals and recommends organizational strategies to improve the safety of medication administration.
Anderson P, Townsend T. Am Nurse Today. May 2015;10:18-23.
High-alert medications have the potential to cause serious patient harm. This article focuses on four primary types of high-alert medications—anticoagulants, sedatives, insulins, and opioids—that can have serious adverse effects and recommends strategies to reduce risks, including conducting independent double-checks and decreasing interruptions.
Verweij L, Smeulers M, Maaskant JM, et al. J Nurs Scholarsh. 2014;46:340-8.
This study used direct observation and interviews to evaluate the effectiveness of tabards, do-not-disturb signs worn by registered nurses dispensing medications in inpatient settings, in preventing disruptions. The authors found a decrease in interruptions and medication errors, suggesting that tabards may augment safety despite controversy regarding their use.
Prakash V, Koczmara C, Savage P, et al. BMJ Qual Saf. 2014;23:884-92.
This study used high-fidelity simulation to evaluate the impact of several interventions on preventing medication administration errors by chemotherapy nurses. Interventions with a basis in human factors engineering principles appeared to be highly effective at reducing errors related to interruptions.
Eggertson L. The Canadian nurse. 2014;110:25-9.
Human factors engineering is being increasingly promoted as an approach that generates lasting safety improvements. This commentary describes how applying human factors principles can identify ways to reduce risks in health care settings, including issues related to interruptions and infusion pumps.
Liu W, Manias E, Gerdtz M. Health Place. 2014;26:188-198.
At an Australian hospital, frequent interruptions, limited space, and equipment problems were among many aspects of the physical environment that hinder the medication administration process. An AHRQ WebM&M perspective discusses how restructuring the physical work environment can be a key component of safety efforts.
Raban MZ, Westbrook JI. BMJ Qual Saf. 2014;23:414-21.
Interruptions are inevitable in the busy clinical environment and may contribute to preventable harm, particularly if they occur during medication administration. This systematic review attempted to synthesize research regarding the effectiveness of interventions that have been tested to limit interruptions during medication administration. These efforts included sterile cockpit approaches derived from the aviation industry. Although some interventions did reduce interruption rates, medication error rates were largely unaffected and the literature has significant methodological flaws. The authors caution that hospitals should not attempt to simply limit interruptions, because there is no clear evidence that doing so will prevent medication errors and some interruptions are necessary for patient care.
Ching JM, Long C, Williams BL, et al. Jt Comm J Qual Patient Saf. 2013;39:195-204.
Errors during administration are one of the most common types of medication errors, with one study showing that they occur in nearly 25% of doses in hospitalized patients. Lean methodology, derived from the Toyota Production System, is increasingly being used in health care as a way to design safer and more efficient systems of care. This study reports on the application of Lean approaches to improving medication administration safety. A redesigned medication administration system that incorporated human factors engineering techniques to minimize interruptions, implement barcode medication administration, and standardize nursing workflows resulted in a significant reduction in administration error rates. The study provides a useful example of how quality improvement techniques originally developed in other industries can be successfully applied in health care.
Colligan L, Guerlain S, Steck SE, et al. BMJ Qual Saf. 2012;21:939-47.
Interruptions during medication administration are a major contributor to medication errors in hospitals. However, interventions to minimize interruptions could have unintended consequences, since certain interruptions are necessary for clinical care. To minimize interruptions while preserving a patient-centered environment, this study used a human factors engineering approach to analyze the medication preparation process and redesign the physical location where the process took place. This approach resulted in significantly fewer interruptions and improved staff satisfaction with medication administration. This study provides an excellent example of how human factors principles can be used to improve the physical environment within a hospital to enhance patient safety.
WebM&M Case October 1, 2012
After having a seizure in the emergency department, a woman was to receive intravenous administration of an antiseizure medication. The nurse misread the medication order, gathered 32 vials of the medication, and administered a 10-fold overdose to the patient, who died several minutes later.
Li SYW, Magrabi F, Coiera E. J Am Med Inform Assoc. 2012;19:6-12.
Interruptions pose a significant safety hazard for health care providers performing complex tasks, such as signout or medication administration. However, as prior research has pointed out, many interruptions are necessary for clinical care, making it difficult for safety professionals to develop approaches to limiting the harmful effects of interruptions. Reviewing the literature on interruptions from the psychology and informatics fields, this study identifies several key variables that influence the relationship between interruption of a task and patient harm. The authors provide several recommendations, based on human factors engineering principles, to mitigate the effect of interruptions on patient care. A case of an interruption leading to a medication error is discussed in this AHRQ WebM&M commentary.