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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 59 Results
Auerbach AD, Astik GJ, O’Leary KJ, et al. J Gen Intern Med. 2023;38:1902-1910.
COVID-19 ushered in new diagnostic challenges and changes in care practices. In this study conducted during the first wave of the pandemic, charts for hospitalized adult patients under investigation (PUI) for COVID-19 were reviewed for potential diagnostic error. Diagnostic errors were identified in 14% of cases; patients with and without diagnostic errors were statistically similar and errors were not associated with pandemic-related change practices.
Adler-Milstein J, Sarkar U, Wachter RM. J Patient Saf Risk Manag. 2022;27:160-162.
… health records (EHR) house and provide access to a plethora of data to inform care and management decisions. … suggests that EHRs have yet to be fully embraced as a tool to proactively identify areas of risk that could lead to legal action. … Adler-Milstein J, Sarkar U, Wachter RM. Opportunities to mine EHRs for malpractice risk …
Stolldorf DP, Mixon AS, Auerbach AD, et al. Am J Health Syst Pharm. 2020;77:1135-1143.
This mixed-methods study assessed the barriers and facilitators to hospitals’ implementation of the MARQUIS toolkit, which supports hospitals in developing medication reconciliation programs. Leadership who responded to the survey/interview expressed limited institutional budgetary and hiring support, but hospitals were able to implement and sustain the toolkit by shifting staff responsibilities, adding pharmacy staff, and using a range of implementation strategies (e.g., educational tools for staff, EHR templates).
Landrigan CP, Rahman SA, Sullivan JP, et al. N Engl J Med. 2020;382:2514-2523.
This multicenter cluster randomized trial explored the impact of eliminating extended-duration  work schedules (shifts in excess of 24 hours) on serious medical errors made by residents in the pediatric intensive care unit (ICU). The authors found that residents in ICUs which eliminated extended shifts in favor of day and night shifts of 16 hours or less made significantly more serious errors than residents assigned to extended-duration work schedules. The authors observed that the resident-to-patient ratio was higher during schedules which eliminated extended shifts, but also that these results might have been confounded by concurrent increases in workload in ICUs eliminating extended shifts.
Landrigan CP, Rahman SA, Sullivan JP, et al. N Engl J Med. 2020;382:2514-2523.
This article presents longitudinal follow-up of the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial, which examined the effects of flexible duty-hour policies on resident outcomes. After four years, there was no evidence of increased duty-hour violations, decreased satisfaction or decreased well-being among residents randomized to flexible duty-hour policies. The researchers also observed that the beneficial impacts of flexible duty-hours persisted over the four-year period, whereas most of the negative effects diminished over time.
Wick EC, Sehgal NL. JAMA Surg. 2018;153:948-954.
This systematic review of opioid stewardship practices following surgery identified eight intervention studies intended to reduce postsurgical opioid use. Organizational-level interventions such as changing orders in the electronic health record, demonstrated clear reductions in opioid prescribing. Clinician-facing interventions such as development and dissemination of local guidelines also led to reduced opioid prescribing. The authors emphasize the need for more high-quality evidence on opioid stewardship interventions.
Auerbach AD, Neinstein A, Khanna R. Ann Intern Med. 2018;168:733-734.
Digital tools have the potential to improve diagnosis, patient self-care, and patient–clinician communication. This commentary argues that digital tools that alter diagnosis or treatment require examination to ensure safety. The authors provide recommendations such as involving experts in evaluating the tools, engaging information technologists, and continuous local review and assessment to identify and address risks associated with use of such tools in practice.
Burke RE, Schnipper JL, Williams M, et al. Med Care. 2017;55:285-290.
… Care … This retrospective cohort study demonstrated that a readmission risk score could prospectively identify … These results suggest that this algorithm can identify a high-risk patient group who may benefit from interventions …
Greysen R, Harrison JD, Kripalani S, et al. BMJ Qual Saf. 2017;26:33-41.
Hospitals with high readmission rates face reductions in Medicare reimbursements. Understanding the patient perspective at the time of readmission may better inform future readmission reduction efforts. Researchers surveyed patients readmitted to the general medicine services within 30 days of discharge across 12 hospitals on multiple aspects of self-care. Although 91% of patients reported understanding of their discharge plan, more than 52% reported difficulty with at least one aspect of self-care after discharge.
Kruger JF, Chen AH, Rybkin A, et al. BMJ Qual Saf. 2016;25:977-985.
Medical imaging overuse is associated with increased rates of cancer related to radiation exposure. Researchers found that displaying radiation exposure and cost information to clinicians ordering radiologic studies may affect their decision to request diagnostic imaging and raise clinician awareness around radiation risks and study costs.
Coffin PO, Behar E, Rowe C, et al. Ann Intern Med. 2016;165:245-252.
Opioid medications carry significant risk of adverse drug events. This observational study found that patients prescribed naloxone to treat overdose in home and community settings were less likely to have opioid-related emergency department visits compared to those not prescribed naloxone. This finding demonstrates the safety benefit of prescribing naloxone in outpatients.
Rosenbluth G, Jacolbia R, Milev D, et al. BMJ Qual Saf. 2016;25:324-8.
… signout sheets decline significantly over the course of a physician shift. This work highlights the need for more real-time updated patient information than a printed page can provide. …
Auerbach AD, Kripalani S, Vasilevskis EE, et al. JAMA Intern Med. 2016;176:484-93.
… medicine … JAMA Intern Med … Preventing readmissions is a cornerstone of patient safety efforts. However, one concern … care goals , and emergency department decisions to readmit a patient who did not require a second inpatient stay. These results suggest that multiple …
Goldman E, Sarkar U, Kessell E, et al. Ann Intern Med. 2014;161:472-81.
… Med … Readmissions and adverse events after discharge are a continued patient safety problem, as evidenced by the fact … These challenges are explored further in an AHRQ WebM&M interview with Dr. Eric Coleman, a pioneer in the field of care transitions and …
Pedroja AT, Blegen MA, Abravanel R, et al. J Patient Saf. 2014;10:168-75.
… events . This observational study sought to develop a metric of hospital system load—a multidimensional measure of overall hospital workload—and … to validate the system load metric, this study provides a new method to quantify system stressors that could affect …
Kaiser S, Asteria-Peñaloza R, Vittinghoff E, et al. Pediatrics. 2014;133:e1139-47.
Codeine is considered a high-risk medication in children due to variability in its metabolization. Despite recommendations against its use, this analysis of national data over a 10-year period found only a slight decrease in codeine prescriptions for children seen in the emergency department.
Martinez W, Hickson GB, Miller BM, et al. Acad Med. 2014;89:482-9.
… regarding error disclosure. Most trainees had observed a harmful medical error, and the majority reported exposure … trainees reported nontransparent behavior in response to a harmful medical error they had made. Addressing the … to advancing full disclosure efforts. An AHRQ WebM&M perspective by Dr. Albert Wu discusses the importance of …
Lee KP, Nishimura K, Ngu B, et al. Ann Pharmacother. 2014;48:168-177.
Medication reconciliation during hospital admission is a Joint Commission National Patient Safety Goal. This study found that patients' personal medication lists were often incomplete, and nearly all of them had at least one discrepancy from clinic medication lists.