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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 28 Results
Estock JL, Codario RA, Keddem S, et al. Diabetes Technol Ther. 2023;25:343-355.
Insulin pump malfunctions are a known contributor to adverse events. This study used six months of adverse events reported to the Food and Drug Administration's (FDA) Manufacturer and User Facility Device Experience (MAUDE) database to identify root causes and consequences of errors associated with insulin pump malfunctions. Hyper- and hypoglycemia were the most common clinical consequences of the malfunction; only half of the reports identified a potential root cause.
Myers JS, Lane-Fall MB, Perfetti AR, et al. BMJ Qual Saf. 2020;29:645-654.
This study used a mixed-methods approach to characterize the impact of two academic fellowships in Quality Improvement Patient Safety (QIPS) to both graduates and their respective institutions. Students in these programs reported a positive impact of the fellowship on their careers, with nearly all being involved in QIPS administration, research or education upon graduation. Interviewed mentors also generally thought the fellowships were important and the resulting research had departmental, institutional and even national importance.
Trowbridge RL, Reilly JB, Clauser JC, et al. Diagnosis (Berl). 2018;5:229-233.
This simulation study presented virtual patient cases to practicing physicians with the aim of improving diagnostic accuracy. Physician participants reported challenges using the computerized platform, and overall diagnostic performance was poor, with less than a third of respondents identifying the correct diagnosis. This study highlights the challenge of developing interventions to enhance diagnostic performance.
Lane-Fall MB, Pascual JL, Peifer HG, et al. Ann Surg. 2020;271:484-493.
Handoffs represent a vulnerable time for patients in which inadequate communication between providers can contribute to adverse outcomes. Research has shown that the use of standardized handoff tools not only improves the process but also decreases errors. In this prospective cohort study, researchers implemented a handoff protocol designed to improve handoffs between the operating room and the intensive care unit (ICU) across two surgical ICUs at two hospitals. They examined omission of information across 13 topics contained in the handoff template before and after implementation. Standardization of the handoff process led to a decrease in omitted information and increased the length of time of the handoff. There was no impact on ICU mortality and length of stay. A past PSNet interview discussed implementation of a standardized handoff tool.
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.
Myers JS, Bellini LM. Acad Med. 2018;93:1321-1325.
Although patient safety competency development is increasingly a goal of graduate medical education, skills to teach them are lacking. This project report describes the development, implementation, and outcomes of a curriculum developed to meet quality improvement and patient safety educational requirements. The approach included activities such as event reporting, root cause analysis, and disclosure simulation.
Chacko KM, Halvorsen AJ, Swenson SL, et al. Am J Med Qual. 2018;33:405-412.
Engaging trainees in quality improvement efforts has been an important area of focus within graduate medical education, but less is known about how health system resources are aligned with these activities. Researchers used survey data to better understand the perceptions of internal medicine residency program directors regarding health system support for and alignment with graduate medical education quality improvement efforts.
Lane-Fall MB, Pascual JL, Massa S, et al. Jt Comm J Qual Saf. 2018;44:514-525.
Standardizing handoffs has been shown to improve patient safety. The authors describe provider perspectives regarding handoffs from the operating room to intensive care unit as well as the development of a standardized OR-to-ICU handoff protocol.
Lane-Fall MB, Davis JJ, Clapp JT, et al. Acad Med. 2018;93:904-910.
This analysis of specialty-specific milestones for graduate medical education found that about 40% mentioned patient safety or quality improvement. Emphasis on patient safety and quality improvement skills varied by specialty. The authors conclude that patient safety concepts are addressed in graduate medical education competencies.
Myers JS, Tess A, McKinney K, et al. J Grad Med Educ. 2017;9:9-13.
It is critical to educate trainees about patient safety. In this study, researchers described lessons learned from creating a leadership role that bridges quality and safety activities with graduate medical education in each of their institutions. Key responsibilities included clinical oversight, faculty development, and educational innovation. The authors advocate for further evaluation of this safety and education leadership role to determine its impact on medical education and patient outcomes.
WebM&M Case March 1, 2017
A woman taking modified-release lithium for bipolar disorder was admitted with cough, slurred speech, confusion, and disorientation. Diagnosed with delirium attributed to hypercalcemia, she was treated with aggressive hydration. She remained disoriented and eventually became comatose. After transfer to the ICU, she was diagnosed with nephrogenic diabetes insipidus due to lithium toxicity.
Caroff DA, Bittermann T, Leonard CE, et al. Jt Comm J Qual Patient Saf. 2015;41:457-461.
This pre-post study found that a standardized pharmacist review of patient medications prior to hospital discharge improved the accuracy of medication reconciliation, with fewer errors uncovered over time. This work adds to the body of evidence supporting pharmacist involvement in medication reconciliation across settings.
Tess A, Vidyarthi A, Yang J, et al. Acad Med. 2015;90:1251-7.
Engaging residents and fellows in quality and safety programs is a recognized strategy to address a gap in medical education. This commentary describes a six-factor framework to integrate safety concepts into graduate medical education curriculum focusing on organizational elements such as culture, interprofessional learning, and faculty development.
Reilly JB, Bennett N, Fosnocht K, et al. Acad Med. 2015;90:450-3.
Maintaining the quality of teaching on resident rounds has become a challenge in light of new pressures to improve value, as well as changes in the organization of care and in trainee accreditation standards. This commentary describes a rounding process that focuses on enhancing safety culture, engaging patients, and improving diagnostic reasoning as goals to reinforce teamwork activities including huddles, bedside rounds, and diagnostic timeouts. The authors provide information drawn from their evaluation of the program and discuss plans for further research building on their work.
Myers JS, Nash DB. Acad Med. 2014;89:1328-1330.
The Clinical Learning Environment Review (CLER) program was developed to evaluate the performance of teaching institutions in six key areas that affect patient outcomes. This commentary describes how poor safety culture in clinical practice can counteract the effect of educating medical students about quality and safety principles. The authors note unintended consequences of the CLER program and strategies to avoid them.
Reilly JB, Myers JS, Salvador D, et al. Diagnosis (Berl). 2014;1:167-171.
This commentary discusses how two medical centers utilized the fishbone diagram as a tool to analyze diagnostic errors. A health care facility in Maine developed a root cause analysis model to determine common factors, and a residency program in Pennsylvania introduced a modified fishbone diagram to educate trainees about cognitive biases and systems issues.
Paciotti B, Roberts KE, Tibbetts KM, et al. Jt Comm J Qual Patient Saf. 2014;40:187-192.
In an effort to provide more timely responses to clinical deteriorations, some pediatric medical centers have enabled family members to directly activate medical emergency teams (METs). This study used semistructured interviews to examine physicians' viewpoints on issues related to family-activated METs. Even though the majority of physicians said they depend on families to identify subtle changes in their child's condition, 93% of respondents reported that families should not be able to access the MET directly. Some concerns included families' lack of medical knowledge and training to determine when a MET is necessary, and the belief that this responsibility could provide an undue burden and stress on family members. These tensions are similar to prior discussions about other efforts to engage patients in their own safety during hospitalization.
Graber ML, Trowbridge RL, Myers JS, et al. Jt Comm J Qual Patient Saf. 2014;40:102-10.
Although diagnostic errors cause considerable morbidity and mortality, thus far organizations have focused on preventing errors that are more easily measured. This commentary provides two examples of organizational approaches to minimizing diagnostic error. In one, Maine Medical Center established a voluntary reporting system for diagnostic error coupled with a revised root cause analysis process to determine both cognitive and systems causes of these errors. In the other example, the Kaiser Permanente system leveraged their electronic medical record to establish electronic "safety nets" to identify patients at risk of diagnostic error. These mainly focused on ensuring appropriate follow-up of abnormal lab tests (particularly cancer screening tests) and sufficient monitoring of high-risk medications. As failure to appropriately follow-up on lab abnormalities is a common source of patient harm in ambulatory care, this system—which identified thousands of patients requiring urgent follow-up—likely averted many cases of preventable harm. An accompanying editorial by Dr. Hardeep Singh encourages health care organizations to develop processes for examining missed opportunities for making timely diagnoses.