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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 35 Results
WebM&M Case December 14, 2022
… by an interventional radiologist. However, the patient’s condition worsened, and he suddenly developed diffuse … Commentary … By Mark Fedyk, PhD, Nathan Fairman, MD, MPH, Patrick S. Romano, MD, MPH, John MacMillan, MD, and Monica … for the management of pain in patients with cancer. N Engl J Med . 1994;330(9):651-655. [ Free full text ] Team …
Zrelak PA, Utter GH, McDonald KM, et al. Health Serv Res. 2022;57:654-667.
The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) are widely used for measuring and reporting hospital quality and patient safety. This paper describes the process of reweighing the composite patient safety indicator (PSI 90) to incorporate excess harm reflecting patients’ preferences for various possible related outcomes (e.g., readmissions, reoperation, long-term care stay, death). Compared to the original frequency-based weighting, some component indicators in the reweighted composite – including postoperative respiratory failure, postoperative sepsis, and perioperative pulmonary embolism or deep vein thrombosis – contributed to the greatest harm.
Chin DL, Wilson MH, Trask AS, et al. J Med Syst. 2020;44:185.
Clinical decision support (CDS) alerts can improve patient safety, and prior research suggests that monitoring alert overrides can identify errors. The researchers describe a novel approach to using existing CDS systems to detect medication prescribing errors based on drug-drug interaction and allergy alert overrides. Dose alert overrides had high sensitivity to detect medication prescribing errors occurring in an inpatient setting.
Forster AJ, Bernard B, Drösler SE, et al. Int J Qual Health Care. 2017;29:548-556.
For the first time, the World Health Organization ICD-11 will include a taxonomy for quality and safety events. Researchers applied the new system to 45 patient safety vignettes gleaned from sources such as AHRQ WebM&M, then they described its strengths and limitations. Explicit identification of adverse events in administrative datasets could improve detection of errors, adverse events, and near misses on a population level.
Southern DA, Burnand B, Droesler SE, et al. Med Care. 2017;55:252-260.
AHRQ Patient Safety Indicators (PSIs) have been utilized to identify safety problems and suboptimal care quality in acute care settings using ICD-9 codes in administrative discharge data. Despite limitations in the accuracy of PSIs, they have been widely employed as a quality metric. The implementation of ICD-10 and diagnosis timing codes necessitate development of a new set of PSIs. This consensus and validation study used a Delphi panel process to determine ICD-10 codes associated with safety and quality concerns. Experts grouped the 640 identified diagnostic codes into 18 PSI categories. Application of these novel PSIs in over 10 years of hospital discharge data uncovered safety problems in 5% of hospitalizations. The authors recommend that these proposed PSIs should be further validated using record review or prospective case review.
Southern DA, Hall M, White DE, et al. Int J Qual Health Care. 2016;28:129-35.
Although the 10th revision of the International Classification of Diseases (ICD-10) was recently introduced in the United States in October 2015, the World Health Organization is already working on the next iteration (ICD-11) to be released in 2018. This survey study of nearly 250 stakeholders from around the world identified priorities for improvements, including the need for code clustering and improved codes for adverse events and diagnosis timing. A related study outlines the recommendations made by the ICD-11 Quality and Safety Topic Advisory Group, advancing specific frameworks to address many of these suggestions.
Dharmar M, Kuppermann N, Romano PS, et al. Pediatrics. 2013;132:1090-7.
Children are at high risk for medication errors in emergency departments (EDs). Physician prescribing has been implicated as the most common source of these errors. This retrospective study found that telemedicine consultations for pediatric critical care were associated with fewer physician-related medication errors among seriously ill children in rural EDs. Telemedicine consultations seemed to reduce medication errors more than traditional telephone consultations. Telemedicine may prove to be an important tool for improving the care of rural patients across many different scenarios.
Austin M, D'Andrea G, Birkmeyer JD, et al. J Patient Saf. 2014;10:64-71.
Despite availability of multiple publicly reported patient safety accountability measures, a composite score for hospital safety has yet to be developed. The Leapfrog Group convened a panel of experts to develop such a score for hospitals in the United States. The group synthesized 26 distinct safety indicators into a score comprised equally of process measures (e.g., barcode medication ordering), which recognize safety efforts, and outcome measures (e.g., catheter-associated infections). The panel also weighted the metrics based on the strength of evidence, the opportunity for improvement (i.e., the variation in performance), and the impact (i.e., the potential number of patients affected). After calculating the score for all US hospitals for which data were available, they found lower scores for rural, publicly owned hospitals with a higher percentage of patients with Medicaid as their insurance.
Volpp KG, Small DS, Romano PS, et al. J Gen Intern Med. 2013;28:1048-55.
Although the 2003 duty hour regulations for resident physicians were intended as a patient safety intervention, concerns were raised that the rules might actually result in patient harm by increasing handoffs. These concerns were allayed by prior studies that found no increase in mortality at teaching hospitals after duty hours were restricted. This follow-up study tracked 5-year outcomes among Medicare patients and found no increase in mortality rates at teaching hospitals compared with less teaching-intensive hospitals. While it now appears clear that the 2003 duty hour limits had little impact on either safety outcomes or clinical outcomes, the effect of further regulations implemented in 2011 remains to be seen.
Volpp KG, Friedman W, Romano PS, et al. Ann Intern Med. 2010;153:826-8.
Examining the evidence on ACGME duty hour standards and patient outcomes, this commentary suggests that rather than implementing one policy at a time, alternative approaches should be assessed to effectively improve clinical and educational outcomes.
Silber JH, Rosenbaum PR, Rosen AK, et al. Med Care. 2009;47.
Implementation of duty hour regulations for medical trainees has not adversely affected clinical outcomes in broad populations of patients. This study also found that overall hospital length of stay did not increase for common medical and surgical conditions after resident duty hours were reduced.