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 671 Results

Anesthesia outside of the OR: cause for patient safety concerns?

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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.

Medication errors: the year in review: January through December 2021.

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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.

Prevent administration of ear drops into the eyes.

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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.

Preventing errors when preparing and administering medications via enteral feeding tubes.

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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.

Safety considerations for challenges when using smart infusion pumps.

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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.

Survey results from pharmacists provide support to enhance the organizational response to codes.

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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.

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Diagnostic Safety

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.

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.

Emergency preparedness: be ready for unanticipated electronic health record (EHR) downtime.

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ISMP Medication Safety Alert! Acute care edition! August 25, 2022:27(17)1-6.

Unanticipated health information system downtime can occur for technical or malicious reasons and healthcare organizations should be prepared for such disruptive events. This article highlights training, planning, simulation, and leadership support as key elements in the successful response to unplanned information system events to manage staff stress and patient safety.

Rethinking use of air-safety principles to reduce fatal hospital errors.

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Health Affairs Forefront. 2022;August 26.

The safety of commercial aviation has been a model for health care, yet achieving their level of reliability has been evasive. This piece suggests that weaknesses in voluntary reporting, hazard communication, and human factors design, all of which are core to aviation's success, are contributing to the lack of similar success in health care.

Algorithm that detects sepsis cut deaths by nearly 20 percent.

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Bushwick S. Scientific American. August 1, 2022.

Sepsis identification is challenging, and delays can be deadly. This article discusses how an artificial intelligence program at one hospital over two years contributed to more timely sepsis diagnosis and treatment.

Fostering ethical conduct through psychological safety.

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Ferrere A, Rider C, Renerte B et al. Sloan Manag Rev. Summer 2022;39-43.

A baseline expectation in a safe organization is that employees feel comfortable and supported when sharing concerns. This article summarizes key results of a large workplace survey to identify cultural elements supporting the psychological safety required to encourage speaking up when ethical or other issues are identified in operations.

Stop using these adult bed rails, warns the Consumer Product Safety Commission.

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Treisman R. National Public Radio. June 6, 2022

Bedrails are used in hospitals and at home to minimize falls despite the potential to contribute to patient harm. This news article summarizes a government recall of ten models of home bed rail devices due to entrapment incidents.

Anesthesiologist group says hospitals can prevent fatal errors like Vanderbilt's.

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Clark C. MedPage Today. June 2, 2022

Transparency and discussion of errors is a hallmark of the culture needed to improve safety. This article summarizes an Anesthesia Patient Safety Foundation statement directing organizations and individuals that provide anesthesia care to protect patients and encourage learning from error. It provides context through a discussion of official reports and investigations of a high-profile incident that culminated in criminal charges for the clinician involved.

Adopt strategies to manage look-alike and/or sound-alike medication name mix-ups.

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ISMP Medication Safety Alert! Acute care edition. June 2, 2022;27(11):1-4.

Minimizing look-alike/sound-alike medication risk is a universal need across health care. This story highlights a primary prevention tool that lists problematic drug names. It shares strategies across the medication use process to reduce errors associated with similarly named and labeled medications such as separate storage areas and tall man lettering.

Are you well positioned to resolve conflicts with the safety of an order? Learning from a physician’s homicide trial and the firing of multiple healthcare workers.

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ISMP Medication Safety Alert! Acute care edition. May 19, 2022;27(10):1-5.

Challenging authority can be difficult but necessary in risky situations. This article examines a serial euthanasia overdose case and how the individuals interfacing with the physician involved sensed the medications ordered were inappropriate, yet said nothing. The piece discusses organizational and individual steps to encourage raising concerns in an appropriate and effective manner.

CMS proposal to suppress hospital safety data angers advocates — agency says COVID disruptions, staff shortages hamper ability to fairly score poor performers.

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Clark C. MedPage Today. May 20, 2022.

Public reporting of safety measures is considered a hallmark of health care transparency. This article discusses a proposed change to reporting requirements in the Hospital-Acquired Condition Reduction Program (HACRP). The change would limit the sharing of patient safety indicator data that informs Care Compare and hospital Medicare reimbursements.

4 actions to reduce medical errors in U.S. hospitals.

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Toussaint JS, Segel KT. Harvard Business Review. April 20, 2022.

The patient safety movement has had mixed results in sustaining improvement and commitment. This commentary discusses strategies to instigate continued energy toward reducing medical error: prioritization of patient safety as a hospital imperative, formation of a National Patient Safety Board, installation of a single national body for incident reporting, and implementation of electronic health record learning systems that flag potential risks.

Survey shows room for improvement with three new best practices for hospitals.

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Medication Safety Alert! Acute care edition. May 5, 2022;27(9):1-5.

Practice changes take time to be fully incorporated into daily work. This article shares survey results examining how hospitals implement best practices to enhance the safe use of oxytocin, improve vaccine administration through bar coding, and deploy multifaceted strategies to reduce high-alert medication errors. Gaps in uptake were reviewed and recommendations for improvement shared.

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.

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