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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 52 Results
WebM&M Case September 28, 2022

This case describes a 20-year-old woman was diagnosed with a pulmonary embolism and occlusive thrombus in the right brachial vein surrounding a  peripherally inserted central catheter (PICC) line (type, gauge, and length of time the PICC had been in place were not noted). The patient was discharged home but was not given any supplies for cleaning the PICC line, education regarding the signs of PICC line infection, or referral to home health services.

Nether KG, Thomas EJ, Khan A, et al. J Healthc Qual. 2022;44:23-30.
Medical errors in the neonatal intensive care unit threaten patient safety. This children’s hospital implemented a robust process improvement program (RPI, which refers to widespread dissemination of process improvement tools to support staff skill development and identify sustainable improvements) to reduce harm in the neonatal intensive care unit. The program resulted in significant and sustainable improvements to staff confidence and knowledge related to RPI tools. It also contributed to improvements in health outcomes, including healthcare-acquired infection.
Curated Libraries
January 14, 2022
The medication-use process is highly complex with many steps and risk points for error, and those errors are a key target for improving safety. This Library reflects a curated selection of PSNet content focused on medication and drug errors. Included resources explore understanding harms from preventable medication use, medication safety...
Mangal S, Pho A, Arcia A, et al. Jt Comm J Qual Patient Saf. 2021;47:591-603.
Interventions to prevent catheter-associated urinary tract infections (CAUTI) can include multiple components such as checklists and provider communication. This systematic review focused on CAUTI prevention interventions that included patient and family engagement. All included studies showed some improvement in CAUTI rates and/or patient- and family-related outcomes. Future research is needed to develop more generalizable interventions.
Jt Comm J Qual Patient Saf. 2021;47:394-397.
Smart infusions pumps with built-in dose error reduction software (DERS) are designed to protect against dosing errors that result in patient harm. This alert summarizes recommendations to enhance the effective implementation and use of smart infusion pumps such as drug library maintenance and pump error report monitoring.
J Patient Saf. 2020;16:s1-s56.
The patient safety evidence base has been growing exponentially for two decades with noted expansion into the non-acute care environment. This special issue highlights eight articles illustrating the range of practices examined in the AHRQ Making Healthcare Safer III report, including rapid response teams and failure to rescue, deprescribing practices and opioid stewardship.   
WebM&M Case April 29, 2020
A 54-year old women with chronic obstructive pulmonary disease was admitted for chronic respiratory failure. Due to severe hypoxemia, she was intubated, mechanically ventilated and required extracorporeal membrane oxygenation (ECMO). During the hospitalization, she developed clotting problems, which necessitated transfer to the operating room to change one of the ECMO components. On the way back to the intensive care unit, a piece of equipment became snagged on the elevator door and the system alarmed.
Tölli S, Kontio R, Partanen P, et al. Perspect Psychiatr Care. 2020;56:785-796.
This study used qualitative methods to understand the experiences of former psychiatric patients that nursing staff considered challenging and that resulted in behavior management interventions (e.g., aggression, self-harm, inappropriate sexual behavior). Interviewed patients cited various reasons for these challenging behaviors, including communication difficulties related to their psychiatric symptoms, stressful feelings such as frustration and fear, coercive nursing culture and restrictive nursing practices. Strategies for managing these behaviors are discussed, as well as core competencies for delivering care based on patients’ needs.
Long E, Barrett MJ, Peters C, et al. Pediatric Anesthesia. 2020;30.
Intubation occurring outside the operating room (OR) is rare but associated with life-threatening adverse events. This review provides an overview of situational, physiological and anatomical contributors to intubation of children outside of ORs; situational challenges – such as human factors or unfamiliar equipment – are most common. Potential solutions to reduce intubation-related adverse events and improve patient safety are discussed, such as systems‐based changes, including a shared mental model, standardization in equipment and its location, checklist use, multi‐disciplinary team engagement and training in the technical and nontechnical aspects of non‐operating room intubation, debrief post–real and simulated events, and regular audit of performance.
Pinkney SJ, Fan M, Koczmara C, et al. Crit Care Med. 2019;47:e597-e601.
This simulation study examined critical care unit nurses' performance in identifying intravenous medications using different equipment types. Researchers found that line labels (attached to each line of tubing) and organizers (which prevent tubing from tangling) significantly improved the accuracy of medication identification compared to usual care. Use of smart pumps required more time and did not improve medication identification accuracy, suggesting that line labels and organizers are an inexpensive and feasible method to enhance medication safety.
Chang BH, Hsu Y-J, Rosen MA, et al. Am J Med Qual. 2020;35:37-45.
Preventing health care–associated infections remains a patient safety priority. This multisite study compared rates of central line–associated bloodstream infections, surgical site infections, and ventilator-associated pneumonia before and after implementation of a multifaceted intervention. Investigators adopted the comprehensive unit-based safety program, which emphasizes safety culture and includes staff education, identification of safety risks, leadership engagement, and team training. Central line–associated bloodstream infections and surgical site infections initially declined, but rates returned to baseline in the third year. They were unable to measure differences in ventilator-associated pneumonia rates due to a change in the definition. These results demonstrate the challenge of implementing and sustaining evidence-based safety practices in real-world clinical settings. A past PSNet interview discussed infection prevention and patient safety.
Bach TA, Berglund L-M, Turk E. BMJ Open Qual. 2018;7:e000202.
Alarm fatigue limits the utility of physiologic monitoring devices intended to keep hospitalized patients safe. The authors conducted a literature review and interviewed experts to identify best practices to optimize device alarms. They present a step-by-step guide to alarm improvement that incorporates a human factors engineering approach.

Azar FM, ed. Orthop Clin North Am. 2018;49(4):A1-A8,389-552.

Quality and value have intersecting influence on the safety of health care. Articles in this special issue explore key principles of safe orthopedic care for both adult and pediatric patients. Topics covered include leadership's role in implementing sustainable improvement, postsurgery patient education as a safety tactic, and the impact of surgical volume on safe, high-quality care.
WebM&M Case October 1, 2017
Hospitalized with sepsis secondary to an infected IV line through which she was receiving treprostnil (a high-alert medication used to treat pulmonary hypertension), a woman was transferred to interventional radiology for placement of a new permanent catheter once the infection cleared. Sign-off between departments included a warning not to flush the line since it would lead to a dangerous overdose. However, while attempting to identify an infusion pump alarm, a radiology technician accidentally flushed the line, which led to a near code situation.
WebM&M Case October 1, 2017
A newborn with elevated total serum bilirubin (TSB) due to hemolytic disease was placed on a mattress with embedded phototherapy lights for treatment, but the TSB continued to climb. The patient was transferred to the neonatal ICU for an exchange transfusion. The neonatologist requested testing of the phototherapy lights, and their irradiance level was found to be well below the recommended level. The lights were replaced, the patient's TSB level began to drop, and the exchange transfusion was aborted.
Gardner AK, Abdelfattah K, Wiersch J, et al. J Surg Educ. 2015;72:e158-62.
This study suggests that incorporating error training into curricula may result in better skill retention. Surgical interns were exposed to either a video showing only correct placement of central venous catheters, or one showing both correct placement and errors. Trainees performed similarly on immediate postcourse tests, but the group that included error training performed significantly better one month later.
WebM&M Case June 1, 2015
A hospitalized older man with a complicated medical history had not voided in several hours. The patient voided just prior to catheter insertion, which produced no urine, and the nurse assumed that meant the patient's bladder was empty. Two hours later the patient complained of discomfort and a blood clot was found in his tubing. Continuous bladder irrigation was ordered, but the pain became worse. Urgent consultation by urology revealed that the urinary catheter was not in the bladder.

Widmer MK, Malik J, eds. Contrib Nephrol. 2015;184:1-270. ISBN: 9783318027051.

Patients with chronic kidney failure are at high risk for adverse events from treatment errors. This publication raises awareness of safety in end-stage renal disease care, explores factors specific to this setting that contribute to failure, and describes techniques for clinicians to reduce risk of errors.
Dunford BB, Perrigino M, Tucker SJ, et al. J Patient Saf. 2017;13:162-168.
Smart infusion pumps, which provide alerts and decision support for high-risk medications, have a proven record of preventing adverse drug events. However, like with all technology users may engage in workarounds that (intentionally or inadvertently) bypass the safety features of the equipment. This qualitative study among nurses at three health systems identified several reasons why nurses used workarounds despite having an overall strong positive perception of smart pumps. While the technology itself necessitated workarounds at times (for example, if the drug to be infused was not in the pump's programmed library), workarounds were more commonly attributed to nontechnical factors such as production pressures or inadequate training. In order to improve adherence to smart pump's safety features, organizations will need to address both technical factors and issues related to nurses' work environment.
WebM&M Case June 1, 2014
Following removal of a central venous catheter placed during his admission for a prolonged course of intravenous antibiotics, a young man with a history of Behçet disease was discharged from the hospital. Shortly thereafter, he presented to the emergency department with acute onset shortness of breath and a "whistling sound" coming from his neck. Diagnosed with air embolism, he was admitted to the ICU.