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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 - 13 of 13 Results
Perspective on Safety March 31, 2022

Errors in medication management and administration are major threats to patient safety. This piece explores issues with opioid and nursing-sensitive medication safety as well as medication safety in older adults. Future research directions in medication safety are also discussed.

Errors in medication management and administration are major threats to patient safety. This piece explores issues with opioid and nursing-sensitive medication safety as well as medication safety in older adults. Future research directions in medication safety are also discussed.

Schwartz A, Peskin S, Spiro A, et al. Diagnosis (Berl). 2020;7:251-256.
Routine depression screening by primary care providers is recommended to decrease risk of suicide and self-harm. Using unannounced standardized patient visits, researchers were able to compare depression screening rates before and after intervention (including personalized provider feedback). Depression screenings were completed more frequently up to one-year postintervention.
Kemper KJ, Schwartz A, Wilson PM, et al. Pediatrics. 2020;145:e20191030.
Physician burnout has been associated with increased patient safety incidents. A recent national survey of pediatric residents found burnout rates exceeded 50%. The survey found that risk of burnout was associated with reported stress, sleepiness, dissatisfaction with work-life balance and recent medical error. Burnout rates were lowest among residents reporting empathy, self-compassion, quality of life, and confidence in providing compassionate care.
Ott M, Schwartz A, Goldszmidt M, et al. Med Educ. 2018;52:851-860.
This observation and interview study examined instances of surgical trainees hesitating in the operating room. Both trainees and attending physicians interpreted hesitation as incompetence. The authors suggest that this interpretation of hesitation does not support progressive autonomy for trainees and must be addressed in order to promote surgical safety.
Binns-Calvey AE, Malhiot A, Kostovich CT, et al. Acad Med. 2017;92:1287-1293.
Contextual errors can occur when health care providers fail to consider a patient's individual context, such as limited literacy, when making a treatment plan. This qualitative study of clinicians identified 12 types of contextual errors that can impede patient self-management and lead to harm. The authors advocate a "contextual differential" to consider these potential errors.
Schwartz A, Weiner SJ, Binns-Calvey A, et al. BMJ Qual Saf. 2016;25:159-63.
This meta-analysis of three pooled studies revealed that patient-specific contextual factors, which may affect the care plan, were more often identified when providers specifically elicited such information rather than when it arose spontaneously. This finding demonstrates the benefits of recommended best practices for safe health communication, discussed in a past PSNet interview.
Weiner SJ, Schwartz A. Acad Med. 2016;91:657-62.
Physicians should consider contextual issues when developing care plans with patients. This commentary discusses how inattention to patient context, such as environmental or social factors, can contribute to medical errors. Contextual factors that physicians should consider include finances, religion, social support, and access to care.
Schwartz A, Weiner SJ, Weaver FM, et al. BMJ Qual Saf. 2012;21:918-24.
Failure to appreciate the role of contextual factors—such as patients' access to care or social support—can result in diagnostic errors. In this analysis of data from a prior study, failure to appropriately individualize care based on contextual factors led to substantial excess costs, often due to prescribing unnecessary medications. The investigators also make the important point that most of these errors would not have been detected by standard quality measures for outpatient care.
Schwartz A, Weiner SJ, Harris IB, et al. JAMA. 2010;304:1191-7.
Medical students who received specific training in probing for contextual factors (biomedical or psychosocial factors that could impact diagnosis or treatment) while interviewing patients were better able to develop individualized treatment plans.
Weiner SJ, Schwartz A, Weaver FM, et al. Ann Intern Med. 2010;153:69-75.
The landmark Institute of Medicine report on patient safety categorized inappropriate plans of care as a medical error. This broad classification encompassed decision-making errors by clinicians that included diagnostic errors but also the notion of contextual errors. The latter are those that occur because of inattention to patient context such as environment, behavior, economic situation, or access to care and social support. This study used unannounced standardized patients who acted out four clinical scenarios presenting with biomedical and contextual complicating factors. Attending physicians probed fewer contextual red flags than biomedical ones and provided error-free plans of care in 73% of the uncomplicated encounters, 22% of the contextually complicated encounters, and only 9% of the combined biomedically and contextually complicated encounters. The authors advocate for greater attention and performance metrics to assess how well providers deliver individualized patient care plans based on probed contextual factors.
Weiner SJ, Barnet B, Cheng TL, et al. Ann Intern Med. 2005;142:709-714.
The authors address obstacles to effective communication with a conceptual framework that includes attention to information exchange among providers, use of information technology, and reduction of external disruptions that affect communication.