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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 18374 Results
Perspective on Safety March 29, 2023

In the past several decades, technological advances have opened new possibilities for improving patient safety. Using technology to digitize healthcare processes has the potential to increase standardization and efficiency of clinical workflows and to reduce errors and cost across all healthcare settings.1 However, if technological approaches are designed or implemented poorly, the burden on clinicians can increase. For example, overburdened clinicians can experience alert fatigue and fail to respond to notifications. This can lead to more medical errors.

WebM&M Case March 29, 2023

An adult woman with a history of suicidal ideation was taking prescribed antidepressants, but later required admission to the hospital after overdosing on her prescribed medications. A consulting psychiatrist evaluated the patient but recommended sending her home on a benzodiazepine alone, under observation by her mother.

WebM&M Case March 29, 2023

A 48-year-old obese man with a history of obstructive sleep apnea was placed under general anesthesia for corneal surgery. On completion of the operation, the patient was transferred to a motorized gurney to extubate him in a sitting position because the operating room (OR) table was too narrow. However, while the team was moving him from the OR table to the gurney, a nurse inadvertently pulled on the anesthetic machine hoses. The endotracheal tube became dislodged and the patient could not be ventilated.

WebM&M Case March 29, 2023

This case describes a 13-year-old girl who presented to several health care providers with typical symptoms, physical signs, and early laboratory findings suggestive of adrenal insufficiency (AI) yet the diagnosis was delayed for several months due to diagnostic biases. After she suffered a sudden cardiac arrest during a visit to her local emergency department and was airlifted to a tertiary care facility, she was found to be in adrenal crisis secondary to Addison’s disease.

WebM&M Case March 29, 2023

This patient with recently diagnosed adenocarcinoma of the esophagus underwent esophagoscopy with endoscopic ultrasound, which was complicated by thoracic esophageal perforation. The perforation was endoscopically closed during the procedure. However, there was a lack of clear communication regarding the operator’s confidence in the success of endoscopic closure and their recommendations for the modality and timing of follow-up imaging, which ultimately led to significant delays in patient care.

Xiao K, Yeung JC, Bolger JC. Eur J Surg Oncol. 2023;49:9-15.
The COVID-19 pandemic has increased adoption of telehealth across various medical specialties, including surgery and oncology. This systematic review including 11 studies (3,336 patients) explored the impact of virtual follow-up appointments after cancer operations. The authors concluded that virtual visits following cancer surgery had similar safety to in-person visits along with high levels of satisfaction for surgeons and patients.
Riesenberg LA, Davis R, Heng A, et al. Jt Comm J Qual Patient Saf. 2022;Epub Dec 15.
Anesthesiologists frequently hand off care of complex, often unstable patients, which can introduce patient safety risks. This systematic review examined the education components of studies seeking to improve anesthesiology handoffs. The authors identified marked heterogeneity in the use of established curriculum development best practices and concluded that more than half of the medical education interventions were of low quality. The authors identify challenges that could be addressed to improve future educational interventions.
Agbar F, Zhang S, Wu Y, et al. Nurse Educ Pract. 2023;67:103565.
Health systems seeking to improve patient safety culture (PSC) implement myriad of educational programs for their staff. This review identified 16 studies of PSC education programs that included before and after surveys or intervention and control groups. Results were generally positive, but repeated trainings may be needed to sustain the change. Additionally, based on the reporting using the AHRQ Hospital Survey of Patient Safety Culture (HSOPS), a culture of blame remained a pervasive problem despite improvements in other components of patient safety culture in many hospitals.
Barlow M, Watson B, Jones EW, et al. BMC Nurs. 2023;22:26.
Healthcare providers may decide to speak up or remain silent about patient safety concerns based on the expected response of the recipient. In this study, clinicians from multiple disciplines responded to two hypothetical speaking up scenarios to explore the impact of communication behavior and speaker characteristics (e.g., discipline, seniority, presence of others) on the recipient’s intended response. Each of the factors played a role in how the clinician received the message and how they would respond.
Sloane JF, Donkin C, Newell BR, et al. J Gen Intern Med. 2023;Epub Jan 25.
Interruptions during diagnostic decision-making and clinical tasks can adversely impact patient care. This article reviews empirically-tested strategies from healthcare and cognitive psychology that can inform future research on mitigating the effects of interruptions during diagnostic decision-making. The authors highlight strategies to minimize the negative impacts of interruptions and strategies to prevent distractions altogether; in addition, they propose research priorities within the field of diagnostic safety.

Kent S. NJ.com. March 12, 2023.

Heuristics, uncertainty, and bias are contributors to diagnostic error, overuse, and treatment delay. This story describes the care experience of an adolescent patient whose rare immune system condition was initially diagnosed as being psychological in origin, which contributed to persistent misdiagnosis.
Hawkins RB, Nallamothu BK. BMJ Qual Saf. 2023;32:181-184.
A 2022 study found that non-first off-pump coronary artery bypass graft (CABG) had a higher risk of complications than first cases, proposing prior workload as a contributing cause. This commentary responds to that study, proposing system and organizational factors, not just the individual surgeon, be taken into consideration as contributing causes.
Yasrebi-de Kom IAR, Dongelmans DA, de Keizer NF, et al. J Am Med Inform Assoc. 2023;Epub Feb 20.
Prediction models are increasingly used in healthcare to identify potential patient safety events. This systematic review including 25 articles identified several challenges related to electronic health record (EHR)-based prediction models for adverse drug event diagnosis or prognosis, including adherence to reporting standards, use of best practices to develop and validate prediction models, and absence of causal prediction modeling.
Petts A, Neep M, Thakkalpalli M. Emerg Med Australas. 2022;Epub Dec 5.
Misinterpretation of radiology test results can contribute to diagnostic errors and patient harm. Using a set of 838 pediatric and adult radiographic examinations, this retrospective study found that radiographers’ interpretations can complement emergency clinicians’ interpretations and increase accuracy compared to emergency clinician interpretation alone.

Donovan-Smith O. Spokesman Review. March 15, 2023.

Implementations of electronic health record (EHR) systems are complex efforts that have the potential for injury, should failure occur. This article discusses the Veterans Affairs EHR implementation project that is associated with six incidents of patient harm and calls for improvement at the federal level.
Brattebø G, Flaatten HK. Curr Opin Anaesthesiol. 2023;36:240-245.
Latent errors or conditions are subtle and can be difficult to identify before an incident occurs. This commentary calls for moving from the reactive "bad apple" paradigm to a proactive just culture, where errors and near misses serve as organizational learning opportunities, and not as a time for individual discipline.
Suclupe S, Kitchin J, Sivalingam R, et al. J Patient Saf. 2023;19:117-127.
Patient identification mistakes can have serious consequences. Using the Systems Engineering for Patient Safety (SEIPS) framework, this qualitative study explored systems factors contributing to patient identification errors during intrahospital transfers. The authors found that patient identification was not completed according to hospital policy during any of the 60 observed patient transfer handoffs. Miscommunication and lack of key patient information were common factors contributing to identification errors.