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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 956 Results

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.

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.

DePeau-Wilson M. MedPage Today. January 13, 2023.

The use of anesthesia in ambulatory settings presents both advantage and risk to patients and clinicians. This article discusses evidence defining these issues. It suggests that improved collaboration with anesthesiologists represents opportunities for nonoperating room anesthesia safety.

Abelson R. New York Times. December 15, 2022.

Emergency department safety is challenged by factors such as production pressure, burnout, and overcrowding. This news article provides context for the 2022 AHRQ report Diagnostic Errors in the Emergency Department: A Systematic Review from the Johns Hopkins Medicine Evidence-based Practice Center (EPC) which synthesized the number of patients harmed while seeking emergency care.

Pharmacy Practice News Special Edition. December 13, 2022: 43-54.

Medication errors continue to occur despite long-standing efforts to reduce them. This article summarizes types of errors submitted to the Institute for Safe Medication Practices reporting program in 2021. The piece discusses the medications involved, recommendations for improvement, and technologies to be employed to minimize error occurrence.

ISMP Medication Safety Alert!: Acute Care Edition. December 1, 2022;27(24):1-3.

Look-alike medications are vulnerable to wrong route and other use errors. This article examines the potential for mistaken application of ear drops into eyes. Strategies highlighted to reduce this error focus on storage, dispensing, administration, and patient education.

ISMP Medication Safety Alert! Acute care edition. November 17, 2022;27(23).

Enteral feeding tube medication delivery presents safety challenges that can cause harm. This article highlights problems with feed tube medication administration. It shares improvement recommendations that include best practice adherence, standardization, monitoring, and patient engagement.

Eldeib D. ProPublica. November 13, 2022.

Pregnancy is recognized as a high-risk condition for both mother and infant. This news story examines the potential for stillbirth and its preventability. Lack of respect for the concerns of mothers, inadequate attention to research, and poor patient education are discussed as contributors to stillbirth.

Meyer TA. Anesthesiology News. October 31, 2022.

Medication use in the surgical environment is complex and high-risk. This article describes steps toward the implementation of medication safety process improvement programs for the operating room. Important steps discussed include assessment, analysis, planning, and implementation.

Rau J.  Kaiser Health News. November 1, 2022.

The COVID-19 pandemic necessitated adjustments in activities across health care to address patient care and staffing demands. This news article discusses COVID-19’s impact on the hospital-acquired condition reduction program, and how 43 percent of US hospitals failed to reach readmission goals.

ISMP Medication Safety Alert! Acute care edition. October 20, 2022;20(21):1-5.

Errors due to inadequate information use with intravenous smart pumps are a safety concern. This article discusses factors that contribute to medication errors and smart pumps, which include out-of-date drug libraries, omitted dose limits, and variable rate infusions. Recommendations for improvement include the creation, testing, and updating of drug libraries.

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.

ISMP Medication Safety Alert! Acute care edition. October 6, 2022;27(20):1-5.

Patient resuscitation is a complex, distinct, team activity that can be prone to error. Pharmacists involved in codes reported concerns including errors with high-alert medications and communication gaps. Improvement recommendations focused on preparation for, actions during and post code phrases which included standardizing the practice of including pharmacists in codes, simulation, and regular debriefing.
Curated Libraries
October 10, 2022
Selected PSNet materials for a general safety audience focusing on improvements in the diagnostic process and the strategies that support them to prevent diagnostic errors from harming patients.

Tahir D. Kaiser Health News. September 26, 2022. 

Negative patient representations in medical records perpetuate stereotypes that can affect care over time. This story discusses how written notes using stigmatizing language reflect bias and physician disrespect that serve as clues to misdiagnosis. Black patients and those patients named as "difficult" were particularly vulnerable to damaging representation in notes.

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.

Donovan-Smith O. Spokesman-Review. September 11, 2022.

Electronic health record (EHR) system issues degrade the data sharing and communication needed to inform safe patient care. This newspaper feature discusses problems with the new Veterans Affairs EHR system from the patient and family perspective in the context of diagnostic and treatment delay.

Mills M. The Guardian. September 3, 2022

Families experiencing medical error can harbor frustration with the system but also with themselves for allowing care mistakes to take their loved one. This first-person account shares the story of a mother’s loss of a daughter to sepsis. The memoir illustrates how lack of respect for a family’s concern contributed to the incident.