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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 55 Results
Huth K, Hotz A, Emara N, et al. J Patient Saf. 2023;19:493-500.
The transition from hospital to home is a vulnerable time as patients may have changes in medications or care needs, or difficulties accessing follow up with an outpatient provider. To reduce adverse events (AE), rehospitalizations, and emergency department visits, this hospital developed a structured discharge bundle based on the I-PASS tool used for inpatient handoffs. AE, rehospitalizations, and emergency department visits were all reduced following implementation of the I-PASS bundle.
Morris J, Schomerus G. Drug Alcohol Rev. 2023;42:1264-1268.
Stigma and bias in healthcare undermine patient safety. This article discusses how stigma associated with alcohol use can impede the delivery of quality health care and contribute to poor patient outcomes. 

Grossman D, Joffe C, Kaller S, et al. Advancing New Standards in Reproductive Health, University of California, San Francisco; 2023.

Overarching policy decisions have the potential to impact systems of care and harm patients. This document reports the preliminary findings of a study examining 50 cases submitted where clinicians modified care standards in response to abortion access limitations. The changes affected the timeliness, quality, safety, cost, and complexity of care delivered to pregnant patients.
Vaughan CP, Burningham Z, Kelleher JL, et al. Acad Emerg Med. 2023;30 :340-348 .
The Enhancing Quality of Prescribing Practices for Older Adults in the Emergency Department (EQUIIPPED) program is a multicomponent intervention intended to reduce potentially inappropriate medication (PIM) prescribing among older adults who are discharged from the emergency department (ED). This cluster-randomized trial set at eight Veterans Health Administration (VA) EDs compared the impact of two approaches to the audit and feedback component of the intervention – active provider feedback using academic detailing (i.e., educational outreach visits to improve clinical decision making) versus passive provider feedback using dashboard based on the Beers criteria. Researchers found that academic detailing significantly improved PIM prescribing compared to sites using the dashboard, but noted that dashboard-based audit and feedback may be a reasonable strategy EDs with limited resources.
Turner A, Morris R, McDonagh L, et al. Br J Gen Pract. 2022;73:e67-e74.
Patient access to electronic health records can improve engagement in care. This qualitative study involving patients and staff at general practices in the United Kingdom highlighted unintended consequences of online access to health records, including challenges with patient health literacy, decreased quality of documentation, and increases in staff workload.
Turner A, Morris R, Rakhra D, et al. Br J Gen Pract. 2021;72:e128-e137.
The UK’s National Health Service (NHS) is increasingly using digital technology to deliver care. Researchers interviewed 19 patients and 18 general practice staff about their experiences with one of the NHS’s digital tools, online (asynchronous) consultations. Unintended consequences related to access to and efficiency of care are discussed.  
Montero-Odasso MM, Kamkar N, Pieruccini-Faria F, et al. JAMA Netw Open. 2021;4:e2138911.
Fall prevention in healthcare settings is a patient safety priority. This systematic review found that most clinical practice guidelines provide consistent recommendations for fall prevention for older adults. Guidelines consistently recommend strategies such as risk stratification, medication review, and environment modification.
Morris AH, Stagg B, Lanspa M, et al. J Am Med Inform Assoc. 2021;28:1330-1344.
… decision-making. The authors of this commentary suggest an alternative, eActions , to reduce clinician burden and … to improved clinical care quality and research. … Morris AH, Stagg B, Lanspa M, et al. Enabling a learning …
Cheraghi-Sohi S, Holland F, Singh H, et al. BMJ Qual Saf. 2021;30:977-985.
Diagnostic error continues to be a source of preventable patient harm. The authors undertook a retrospective review of primary care consultations to identify incidence, origin and avoidable harm of missed diagnostic opportunities (MDO). Nearly three-quarters of MDO involved multiple process breakdowns (e.g., history taking, misinterpretation of diagnostic tests, or lack of follow up). Just over one third resulted in moderate to severe avoidable patient harm. Because the majority of MDO involve several contributing factors, interventions, including policy changes, should be multipronged.

Morris S, O’Hara J. Pharmacuetical Journal. February 26, 2021.

It is a challenge to track medical errors that take place in the home environment, yet it is understood they happen and can cause harm. This article discusses errors that parents make in providing medications to their children. The authors advocate for engaging parents as partners to improve care safety in the home.
Kim CS, Meo N, Little D, et al. Jt Comm J Qual Patient Saf. 2021;47:60-68.
This article describes the implementation of the University of Washington Medicine’s COVID-19 surge management plan, which included changes to space, supply management, and staffing plans. Based on their experiences, the authors share key insights and strategies for policymakers and health system decision-makers who are preparing for the next wave of COVID-19 or for a future pandemic. 
Rhee C, Baker M, Vaidya V, et al. JAMA Netw Open. 2020;3:e2020498-e.
Patients have reported delaying or forgoing routine, urgent, and emergent health care during the COVID-19 pandemic. This cohort study included patients admitted to one large US academic medical center to assess the incidence of hospital-acquired COVID-19 during the first weeks of the pandemic. Among hospitalized patients who tested positive for COVID-19 (n=697) and patients discharged after non-COVID-19-related hospitalizations (n=8,370), only two cases were deemed to be hospital-acquired. These findings suggest that hospital-acquired COVID-19 was rare during the height of the pandemic and may reassure patients who are delaying or forgoing health care due to concerns about transmission.  
Franklin BJ, Gandhi TK, Bates DW, et al. BMJ Qual Saf. 2020;29:844–853.
Huddles are one technique to enhance team communication, identify safety concerns and built a culture of safety. This systematic review synthesized 24 studies examining the impact of either unit-based or hospital-wide/multiunit safety huddles. The majority of studies were uncontrolled pre-post study designs; only two studies were controlled and quantitatively measured intervention adoption and fidelity. Results for unit-based huddle programs appear positive. Given the limited number of studies evaluating hospital-wide huddle programs, the authors conclude that there is insufficient evidence to assess the benefit. Further research employing strong methodological designs is required to definitively assess the impact of huddle programs.
Loftus TJ, Hall DJ, Malaty JZ, et al. Acad Psychiatry. 2019;43:581-584.
Resident physicians complete an annual evaluation of their training program, which includes questions on their program's culture of safety. Conducted among residency programs at a single academic medical center, this analysis found that residents in programs that emphasized safety culture had higher rates of passing their board certification exams on the first attempt.
Ansari SP, Rayfield ME, Wallis VA, et al. J Patient Saf. 2020;16:e359-e366.
This study describes a multidisciplinary human factors training intervention for labor and delivery care that included communication training and simulation work. Researchers found that safety culture improved compared to preintervention scores.
Vijayakumar S, Duggar WN, Packianathan S, et al. Front Oncol. 2019;9:302.
Huddles are increasingly being used to improve safety in hospitals. This commentary describes how one hospital implemented structured multidisciplinary prospective peer review of radiation oncology patient treatment plans to help prevent harm and reduce errors. The authors discuss safety culture and minimizing clinical hierarchy as drivers of success.
Sellers MM, Berger I, Myers JS, et al. J Surg Educ. 2018;75:e168-e177.
This qualitative study examined incident reports about surgical patients, comparing trainee reports to those submitted by attending surgeons and nurses. Trainees were more likely to enter reports anonymously and completed more elements for each report, but they also used more blame language and submitted fewer reports overall. The results suggest that encouraging trainee reporting may shed light on surgical safety.
Jones L, Pomeroy L, Robert G, et al. BMJ Qual Saf. 2019;28:198-204.
This qualitative study employed observation, interviews, and review of documents to examine six health care organizations' efforts to improve their governing processes. Researchers found that the presence of a functioning board and the availability of adequate time and resources to improve were the key factors in enhancing organizational performance. The authors highlight the importance of focusing on these contextual factors when seeking improvement, particularly in public sector health systems.