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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 - 10 of 10 Results
Patel SJ, Ipsaro A, Brady PW. Hosp Pediatr. 2022;12:317-324.
Diagnostic uncertainty can arise in complex clinical scenarios. This qualitative study explored how physicians in pediatric emergency and inpatient settings mitigate diagnostic uncertainty. Participants discussed common mitigation strategies, such as employing a “diagnostic pause.” The authors also noted outstanding gaps regarding communicating diagnostic uncertainty to families.
Marshall TL, Rinke ML, Olson APJ, et al. Pediatrics. 2022;149:e2020045948D.
… … Reducing diagnostic errors in pediatric care remains a critical area of research and quality improvement. This … develop effective interventions to reduce these errors. … Marshall TL, Rinke ML, Olson APJ, et al. Diagnostic error in pediatrics: a narrative review. Pediatrics. 2022;149(Suppl …
Orenstein EW, Kandaswamy S, Muthu N, et al. J Am Med Inform Assoc. 2021;28:2654-2660.
Alert fatigue is a known contributor to medical error. In this cross-sectional study, researchers found that custom alerts were responsible for the majority of alert burden at six pediatric health systems. This study also compared the use of different alert burden metrics to benchmark burden across and within institutions.
Ipsaro AJ, Patel SJ, Warner DC, et al. Hosp Pediatr. 2021;11:334-341.
Understanding physician communication regarding diagnostic uncertainty is an important component of reducing diagnostic error. This article outlines a process for identifying pediatric inpatients with uncertain diagnoses and improving shared recognition among interdisciplinary health care teams.
Sump CA, Marshall TL, Ipsaro AJ, et al. Diagnosis. 2021;8:353-357.
Diagnostic uncertainty has been described as a clinician perception that affects diagnostic evaluation and can lead to diagnostic errors and negative patient outcomes. This single site cross-sectional study describes the clinical characteristics and healthcare utilization among pediatric patients prospectively identified as having an ‘uncertain diagnosis’ (defined as patients with high likelihood to have a different diagnosis resulting in a change in management). Of the 200 patients meeting inclusion criteria, 45% had gastrointestinal symptoms (e.g., vomiting, abdominal pain, diarrhea). Five percent of patients (5%) required a rapid response team and 3.5% were transferred to intensive care. The authors suggest that better methods to prospectively identify patients with an ‘uncertain diagnosis’ can result in optimized care for these patients.
Hagedorn PA, Singh A, Luo B, et al. J Hosp Med. 2020;15:378-380.
Secure text messaging has emerged as one method to improve communication between providers and nurses. This paper discusses concerns over alarm fatigue, communication errors and omitting critical verbal communication and provides proposed solutions to support appropriate and effective use of text messaging in a healthcare setting. 
Hagedorn PA, Kirkendall E, Kouril M, et al. JAMA Pediatr. 2017;171:392-393.
… errors in pediatric patients . Investigators used a trigger tool to detect weight-entry errors in the … urgent and emergent settings. These findings suggest that a weight-entry trigger tool can identify pediatric patients at risk for dosing errors. … Hagedorn PA, Kirkendall ES, Kouril M, et al. Assessing …
Kirkendall ES, Kouril M, Dexheimer JW, et al. J Am Med Info Assoc. 2016;24:295-302.
The availability of decision support in computerized provider order entry (CPOE) systems has improved the ability to detect and prevent medication errors before they reach patients. However, when CPOE systems generate an excessive number of safety warnings that prescribers must manually override, alert fatigue may occur. In this study, investigators used a trigger tool approach and reviewed all antibiotic prescriptions with overridden alerts. They found that antibiotic prescriptions with overridden alerts were associated with dosing errors. In many cases, antibiotic overdoses reached patients and led to symptoms. The investigators used this data to refine the alert system, which eliminated some useless alerts. The authors conclude that automated algorithm-based detection systems can enhance the relevance of CPOE medication alerts and thereby reduce medication errors. A recent WebM&M commentary described a medication overdose related to alert fatigue.