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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 81 Results
Benishek LE, Kachalia A, Daugherty Biddison L. JAMA. 2023;329:1149-1150.
The quality and culture of the health care work environment is known to affect care delivery. This commentary discusses human-centered and participatory design approaches as avenues for developing improvements in clinician well-being that will enhance safety for staff, providers, and patients.
Wu AW, Sax H, Letaief M, et al. J Patient Saf Risk Manag. 2020;25:137-141.
In this editorial, patient safety experts discuss threats to healthcare safety and quality due to the COVID-19 pandemic (e.g., failures in infection prevention and control, diagnostic errors, issues with laboratory testing) and highlight positive changes and opportunities, such as improved care coordination, supply chain innovations, accelerated learning, expansion of telemedicine, and prioritizing the safety and well-being of health care workers.
Gartland RM, Myers LC, Iorgulescu JB, et al. J Patient Saf. 2020;17:576-582.
… … This study reviewed medical malpractice claims spanning a 10-year period involving deaths related to inpatient care. Two physicians completed a blinded review of the claim to determine whether there was … was not associated with either the likelihood of payout on a malpractice or the median size of that payout. They …
Mello MM, Roche S, Greenberg Y, et al. BMJ Qual Saf. 2020;29:895-904.
Communication-and-resolution programs (CRP) emphasize early disclosure of adverse events and proactive approaches to resolving the patient safety issue, but successful implementation has been challenging. This study used qualitative methods to explore factors supporting successful CRP implementation at two Massachusetts hospitals. Identified facilitators of successful implementation encompassed institutional leadership support including oversight by a full-time project manager, investments in physician training, positive relationships between hospital risk management and the liability insurer, use of formal decision protocols, collaborative group implementation, and small hospital size.
Williams S, Fiumara K, Kachalia A, et al. Jt Comm J Qual Saf. 2020;46:44-50.
A lack of closed-loop feedback systems has been identified as one contributor to underreporting of patient safety events. This paper describes one large academic medical center’s implementation of a Feedback to Reporter program in ambulatory care, which aimed to ensure feedback on safety reports is provided to reporting staff by managers. At baseline, 50% of staff who requested feedback ultimately received it; after three years, the rate of feedback to reporters had increased to 90%.
Mendu ML, Lu Y, Petersen A, et al. BMJ Qual Saf. 2020;29.
This paper discusses the implementation of a hospital-wide, automated electronic reporting system that was intended to capture real-time data about patient deaths and allows the front-line physicians and nurses to review incident data. Over a 7-year period, 91% of deaths resulted in a review, and 5% were considered preventable by the front-line clinicians. The retrospective study identified potential systems-level changes to improve care delivery and patient safety, particularly around communication, end of life care, and interhospital transfers.
Odell DD, Quinn CM, Matulewicz RS, et al. J Am Coll Surg. 2019;229:175-183.
… College of Surgeons … J Am Coll Surg … Establishing a strong culture of safety is an important priority in the … and patient outcomes has produced mixed results . Using a modified version of the Safety Attitudes Questionnaire … than frontline health care providers. They also found a significant association between improved safety culture as …
Desai S, Fiumara K, Kachalia A. J Patient Saf. 2021;17:e84-e90.
Outpatient safety is gaining recognition as a focus of research and improvement efforts. This project report describes an ambulatory safety program at an academic health system that targeted reporting, safety culture measurement, medication safety, and test result management. Repeated tracking over a 5-year period revealed that failure to request feedback played a role in the modest incident and concern reporting captured by the program. Decentralizing reporting response responsibilities throughout the system significantly increased feedback activity.
Coughlin JM, Shallcross ML, Schäfer WLA, et al. J Surg Res. 2019;239:309-319.
Prior studies have found that patients are often prescribed opioids inappropriately after undergoing surgery. This qualitative study reports on the implementation of a multifaceted effort to reduce opioid prescribing and standardize postoperative pain management at an academic hospital. The investigators identified several barriers to improving prescribing, including time and resource constraints and fear of harming patient satisfaction.
Kachalia A, Sands K, Van Niel M, et al. Health Aff (Millwood). 2018;37:1836-1844.
… respond to serious errors and adverse events. Rather than a deny-or-defend strategy, CRPs facilitate full error … have had great success with CRPs and most see them as a morally wise approach to errors. However, concerns that … Communication-and-resolution programs had either a positive or neutral effect on all metrics including new …
Cochon L, Lacson R, Wang A, et al. J Am Med Info Asso. 2018;25:1507-1515.
As the diagnostic safety field has matured, researchers are striving to better define the diagnostic process and identify failure modes that may lead to patient harm. This study utilized human factors engineering approaches to characterize the information sources used in radiologic diagnostic imaging according to the Systems Engineering Initiative for Patient Safety (SEIPS) framework. Most potential errors were related to person-related factors, such as inadequate communication between clinicians, rather than technological factors.
Canan C, Polinski JM, Alexander C, et al. J Am Med Inform Assoc. 2017;24:1204-1210.
Safer opioid prescribing requires that providers and systems are able to identify patients who misuse or divert opioids. This systematic review assessed different automated algorithms to detect population-level nonmedical opioid use. The authors suggest that algorithms that integrate claims data with natural language processing or other advanced informatics techniques yield the best results.
Gupta A, Snyder A, Kachalia A, et al. BMJ Qual Saf. 2017;27:53-60.
Characterization of diagnostic error in the hospital setting has traditionally relied on data from autopsy studies, but the continuing decline in autopsy rates necessitates identification of diagnostic errors through other data sources. In this study, investigators utilized the National Practitioner Data Bank to examine the incidence and severity of inpatient diagnostic error and estimate the clinical and economic consequences of these errors. Diagnostic error accounted for 22% of paid malpractice claims over a 12-year period, resulting in $5.7 billion in payments, and the incidence of claims due to failure to diagnose increased over time. Paid claims due to diagnostic error were more likely to be for male patients older than 50, compared with other types of paid claims. Consistent with other studies, a small proportion (9%) of physicians accounted for a large proportion (51%) of payments. Although paid malpractice claims data have important limitations, this study advances our understanding of the epidemiology of diagnostic error among hospitalized patients and insights into possible preventive mechanisms.