Skip to main content

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.

Search All Content

Search Tips
Filter By Author(s)
Advanced Filtering Mode
Date Ranges
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Additional Filters
Displaying 1 - 8 of 8 Results
Pool N, Hebdon M, de Groot E, et al. Front in Public Health. 2023;11:1014773.
Clinical decision-making can be influenced by both individual and team factors. This article describes the de Groot Critically Reflective Diagnoses Protocol (DCRDP), which can be used to evaluate how group dynamics and interactions can influence collective clinical decision-making. Transcripts of recorded decision-making meetings can be coded based on six DCRPD criteria (challenging groupthink, critical opinion-sharing, research utilization, openness to mistakes, asking and giving feedback, and experimentation), which identify teams that are interactive, reflective, higher functioning, and more equitable.
Fonarow GC. JAMA. 2018;320:2539-2541.
Using financial incentives to motivate health care improvement can have unintended consequences. This commentary examines how the Centers for Medicare and Medicaid Services Hospital Readmissions Reduction Program may have unintended consequences for postdischarge heart failure patients. The authors advocate for development of more effective policies and measures to reduce the potential for patient harm resulting from well-intentioned improvement efforts.
Gupta A, Allen LA, Bhatt DL, et al. JAMA Cardiol. 2018;3:44-53.
Readmissions are a focus of patient safety efforts, especially in light of Medicare's nonpayment policy. This retrospective, interrupted time-series analysis examined whether reduction in readmissions for heart failure led to any change in health outcomes. This study analyzed data from a national clinical registry of patients with heart failure admitted between 2006 and 2014, spanning the implementation of Medicare nonpayment. Similar to prior studies, there was a decline in readmission rates observed after implementation of penalties. In this cohort, researchers also observed increases in 30-day and 1-year risk-adjusted mortality. The authors conclude that penalties for readmissions may have unintended negative consequences for patient outcomes. A previous PSNet interview discussed the benefits and limitations of Medicare's nonpayment policy.
Tsai TT, Maddox TM, Roe MT, et al. JAMA. 2009;302:2458-64.
Patients hospitalized for cardiac problems are vulnerable to experiencing medication errors, as they are commonly prescribed high-risk medications such as anticoagulants and antiplatelet agents. This analysis of more than 22,000 hemodialysis patients undergoing percutaneous coronary interventions (PCI) (for example, angioplasty) found that 22.3% were administered either enoxaparin or eptifibatide, medications that are contraindicated in dialysis patients due to excessive bleeding risk. This risk was borne out in the study, as patients who received the contraindicated medications did in fact have more major bleeding episodes. The high prevalence of serious medication errors in this study argues for education and use of forcing functions to prevent misuse of these medications.
WebM&M Case September 1, 2007
… The Case … A 75-year-old man with a history of hypertension, coronary … [go to PubMed] 10. Fonarow GC, Heywood JT, Heidenreich PA, et al. Temporal trends in clinical … [go to PubMed] 11. Fonarow GC, LaBresh KA, Yancy C, et al. Reliability of heart failure patient care: …
Alexander KP, Chen AY, Roe MT, et al. JAMA. 2005;294:3108-16.
Treatment of acute coronary syndromes (ACS) benefits from extensive research outlining evidence-based practices for improving the quality of such care. This study discovered that more than 40% of patients presenting with ACS received at least one dose of an antithrombotic medication outside the recommended dosing range. These excess doses lead to greater risks of bleeding; the investigators estimate that 15% of patients experience major bleeding due to these prescribing errors. The findings suggest an alarmingly high rate of potential errors and adverse outcomes for ACS patients. The risks also seem directed at vulnerable populations such as elderly patients with specific comorbidities (eg, diabetes, renal insufficiency, and heart failure). With appropriate increases in utilization of antithrombotic agents for conditions such as ACS, greater attention must focus on safe initial dosing practices to prevent adverse drug events.