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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 62 Results
Hibbert PD, Molloy CJ, Schultz TJ, et al. Int J Qual Health Care. 2023;35:mzad056.
Accurate and reliable detection and measurement of adverse events remains challenging. This systematic review examined the difference in adverse events detected using the Global Trigger Tool compared to those detected via incident reporting systems. In 12 of the 14 included studies, less than 10% of adverse events detected using the Global Trigger Tool were also found in corresponding incident reporting systems. The authors of the review emphasize the importance of using multiple approaches and sources of patient safety data to enhance adverse event detection.
Alqenae FA, Steinke DT, Carson-Stevens A, et al. Ther Adv Drug Saf. 2023;14:204209862311543.
Medication errors and adverse drug events (ADE) are unfortunately common at hospital discharge. This study used the National Reporting and Learning System (NRLS) in England and Wales to identify contributing causes to medication errors and ADE. Patients over 65 were the most common age group and, of incidents with a stated level of harm, most did not result in any harm. Overall, most incidents occurred at the prescribing stage, but varied by patient age group. Most contributory factors were organizational (e.g., continuity of care between provider types), followed by staff, patient, and equipment factors.
Keers RN, Wainwright V, McFadzean J, et al. PLOS One. 2023;18:e0282021.
Prisons present unique challenges in providing, as well as in measuring, safe patient care. This article describes structures and processes within prison systems that may contribute to avoidable harm, such as limited staffing and security to travel to healthcare appointments. The result is a two-tier definition taking into consideration the unique context of prison healthcare.
Cooper A, Carson-Stevens A, Cooke M, et al. BMC Emerg Med. 2021;21:139.
Overcrowding in the emergency department (ED) can result in increased frequency of medication errors, in-hospital cardiac arrest, and other patient safety concerns. This study examined diagnostic errors after introducing a new healthcare service model in which emergency departments are co-located with general practitioner (GP) services. Potential priority areas for improvement include appropriate triage, diagnostic test interpretation, and communication between GP and ED services.
Cooper A, Carson-Stevens A, Edwards M, et al. Br J Gen Pract. 2021;71:e931-e940.
… Br J Gen Pract … In an effort to address increased patient … resulting patient safety concerns , England implemented a policy of general practitioners working in or alongside … making, and improving communication between services. … Cooper A, Carson-Stevens A, Edwards M, et al. Identifying …
Urquhart A, Yardley S, Thomas E, et al. J R Soc Med. 2021;114:563-574.
J R Soc Med … This mixed-methods study analyzed patient … were the most common contributors to incidents. … Urquhart A, Yardley S, Thomas E, et al. Learning from patient safety … adults in hospital assessment units in England and Wales: a mixed methods analysis for quality improvement. J R Soc …
Alshehri GH, Keers RN, Carson-Stevens A, et al. J Patient Saf. 2021;17:341-351.
Medication errors are common in mental health hospitals. This study found medication administration and prescribing were the most common stages of medication error. Staff-, organizational-, patient-, and equipment-related factors were identified as contributing to medication safety incidents.
Avery AJ, Sheehan C, Bell BG, et al. BMJ Qual Saf. 2021;30:961-976.
Patient safety in primary care is an emerging focus for research and policy. The authors of this study retrospectively reviewed case notes from 14,407 primary care patients in the United Kingdom. Their analysis identified three primary types of avoidable harm in primary care – problems with diagnoses, medication-related problems, and delayed referrals. The authors suggest several methods to reduce avoidable harm in primary care, including optimizing existing information technology, enhanced team communication and coordination, and greater continuity of care.
Gibson R, MacLeod N, Donaldson LJ, et al. Addiction. 2020;115:2066-2076.
Methadone and buprenorphine are commonly prescribed to treat opioid use disorder, but their use presents patient safety risks. Using national data from England and Wales, this study analyzed 2,284 patient safety incident reports and found that harmful incidents involving opioid substitution treatment with methadone or buprenorphine in community-based care stemmed from errors in dispensing practices (e.g. wrong patient, incorrect dose, incorrect formulation). Staff- and organization-related factors – such as not following protocols, poor continuity of care – contributed to more than half of the incidents.
Wiig S, Hibbert PD, Braithwaite J. Int J Qual Health Care. 2020;32.
The authors discuss how involving families in the investigations of fatal adverse events can improve the investigations by broadening perspectives and providing new information, but can also present challenges due to emotions, trust, and potential conflicts in perspectives between providers and families.
Hibbert PD, Thomas MJW, Deakin A, et al. Int J Qual Health Care. 2020;32:184-189.
Based on 31 root cause analysis reports of surgical incidents in Australia, this study found that the most commonly retained surgical items were surgical packs (n=9) and drain tubes (n=8). While most retained items were detected on the day of the procedure (n=7), about 16% of items were detected 6-months or later post-procedure. The study found that complex or lengthy procedures were more likely to lead to a retained item, and many retained items, such as drains or catheters, occur in postoperative settings where surgical counts are not applicable.
Omar A, Rees P, Cooper A, et al. Arch Dis Child. 2020;105:731-777.
Using a national database of patient safety incident reports in the United Kingdom, this study characterized primary care-related incidents among vulnerable children and used thematic analysis to identify priority areas for systems improvement. Over 1,100 incident reports were identified; nearly half resulted in some degree of harm but most (39%) were considered ‘low harm.’ Children with  protection-related vulnerabilities experienced harm from unsafe care more frequently than children with social-, psychological, or physical vulnerabilities. The authors identified system priority action areas to mitigate harm among vulnerable children, including improving provider access to accurate information and reducing delays in provider referrals.
Hussain F, Cooper A, Carson-Stevens A, et al. BMC Emerg Med. 2019;19:77.
This retrospective study reviewed incident reports to characterize diagnostic errors occurring in emergency departments in England and Wales. The majority of incidents (86%) were delayed diagnoses; the remainder were wrong diagnoses. The authors identified three themes stemming from human factors that contributed to the diagnostic errors: insufficient assessment (e.g., failure to order imaging or refer patients when indicated), inappropriate response to diagnostic imaging, and failure to order diagnostic imaging. Potential interventions to address these contributors are briefly discussed.
Dinnen T, Williams H, Yardley S, et al. BMJ Support Palliat Care. 2019.
Advance care planning (ACP) allows patients to express and document their preferences about medical treatment; however, there are concerns about uptake and documentation due to human error. This study used patient safety incident reports in the UK to characterize and explore safety issues arising from ACP and to identify areas for improvement. Over a ten-year period, there were 70 reports of an ACP-related patient safety incident (due to incomplete documentation, inaccessible documentation or miscommunication, or ACP directives not being followed) which led to inappropriate treatment, transfer or admission. The importance of targeting the human factors of the ACP process to improve safety is discussed. The PSNet Human Factors Engineering primer expands on these concepts.  
Mitchell R, Faris M, Lystad R, et al. Appl Ergon. 2020;82:102920.
The ability to use administrative data that already exists in the system to classify patient safety events is an important step in understanding patient safety events. This retrospective cohort study set in Australia used the WHO International Classification for Patient Safety (ICPS) to identify characteristics and risk factors of preventable deaths resulting from medical or surgical complications. The researchers took findings from coroner’s reports and classified those findings based on the ICPS. Based on the coroner's findings, clinical process and procedures, medication/IV fluids, and healthcare-association infections or complications were the most common causes of death.
Donaldson LJ, Lemer C, Titcombe J. BMJ. 2019;365:l2037.
This commentary recommends that health care structure the work environment to address conditions that allow for failure. The authors discuss how increased commitment to collective accountability for improvement will result in the robust infrastructure, proactive risk assessment, and cultural conditions needed to ensure patient safety.
Williams H, Donaldson SL, Noble S, et al. Palliat Med. 2019;33:346-356.
Patients receiving palliative care are often medically complex and may be at increased risk for safety events, especially when cared for outside of routine clinic hours. In this mixed-methods study, researchers analyzed patient safety incident reports regarding patients who received inadequate palliative care during nights and weekends from primary care services in the United Kingdom. Incidents related to medications were common, accounting for 613 out of the 1072 safety events included in the study.
Stockwell DC, Landrigan CP, Toomey SL, et al. Hosp Pediatr. 2019;9:1-5.
The groundbreaking National Academy of Medicine report Unequal Treatment highlighted the pervasive nature of racial and ethnic disparities in United States health care. Racial and ethnic minorities experience more adverse events, including adverse drug events and hospital-acquired infections. Investigators used a pediatric global trigger tool to delineate disparities in safety events for a large, random sample of pediatric patients across 16 hospitals (4 hospitals in each US region). Latino children experienced nearly twice the rate of adverse events when compared with white children. Publicly insured children also had a higher adverse event rate. An accompanying editorial reviews study limitations and highlights the need to develop risk-prediction models for different types of adverse events.