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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 44 Results
Ducey A, Donoso C, Ross S, et al. Sociol Health Illn. 2023;45:346-365.
Research has identified variations in treatment that are unlikely to be related to patient characteristics, such as region. In this study, surgeons describe their preferences for and experiences with a device which caused widespread harm to women and was ultimately recalled by several patient safety agencies: transvaginal mesh for the treatment of pelvic floor devices in women. Even when surgeons arrived at the same decision (to perform surgery or not), wide variations were observed during the decision-making process.
Armstrong BA, Dutescu IA, Tung A, et al. Br J Surg. 2023;110:645-654.
Cognitive biases are a known source of misdiagnosis and post-operative complications. This review sought to identify the impact of cognitive biases on surgical performance and patient outcomes. Through thematic analysis of 39 studies, the authors identified 31 types of cognitive bias across six themes. Importantly, none of the included studies investigated the source of cognitive bias or mitigation strategies.
Armstrong BA, Dutescu IA, Nemoy L, et al. BMJ Qual Saf. 2022;31:463-478.
Despite widespread use of surgical safety checklists (SSC), its success in improving patient outcomes remains inconsistent, potentially due to variations in implementation and completion methods. This systematic review sought to identify how many studies describe the ways in which the SSC was implemented and completed, and the impact on provider outcomes, patient outcomes, and moderating factors. A clearer positive relationship was seen for provider outcomes (e.g., communication) than for patient outcomes (e.g., mortality).
Pinkney SJ, Fan M, Koczmara C, et al. Crit Care Med. 2019;47:e597-e601.
This simulation study examined critical care unit nurses' performance in identifying intravenous medications using different equipment types. Researchers found that line labels (attached to each line of tubing) and organizers (which prevent tubing from tangling) significantly improved the accuracy of medication identification compared to usual care. Use of smart pumps required more time and did not improve medication identification accuracy, suggesting that line labels and organizers are an inexpensive and feasible method to enhance medication safety.
Lapointe-Shaw L, Bell CM, Austin PC, et al. BMJ Qual Saf. 2020;29:41-51.
Medication reconciliation is an important component of strategies for preventing adverse events after hospital discharge. Studies show that comprehensive medication interventions (including medication reconciliation) by hospital-based pharmacists can reduce adverse events and readmissions in older patients. This Canadian study sought to evaluate whether medication reconciliation and education by community pharmacists could also achieve the same aims for recently discharged patients. This nonrandomized study used propensity score analysis to evaluate outcomes of patients who received medication reconciliation and review of medication adherence performed by community pharmacists during a dedicated visit. Researchers found that patients receiving the service had a reduction in readmissions and death. The magnitude of benefit was small overall, but it was larger in patients who were filling a new prescription for a high-risk medication. Although the nonrandomized design precluded firmer conclusions, this study indicates that community-based medication reconciliation and review may be a promising strategy for reducing adverse events after discharge.
Urbach DR, Dimick JB, Haynes AB, et al. BMJ. 2019;366:l4700.
Checklists are a popular yet controversial strategy for improving the safety of frontline care. The authors in this commentary debate the weaknesses and strengths of checklists through a discussion of the evidence.
Campbell RJ, El-Defrawy SR, Gill SS, et al. JAMA Ophthalmol. 2019;137:58-64.
Prior work has demonstrated that surgical outcomes differ depending on individual practitioner skill, and concerns have been raised regarding the need to assess skills of aging physicians. This study examined whether cataract surgery outcomes differ for late-career ophthalmologists, defined as those who completed medical school at least 25 years ago, compared to mid-career ophthalmologists, who completed medical school 15 to 25 years ago. This secondary data analysis of all single-eye cataract surgeries performed in Ontario between 2009 and 2013 found that almost 30% of procedures were performed by late-career practitioners. Overall, adverse surgical events did not differ by career stage, although very small increases in risk of two specific complications—dropped lens fragment and endophthalmitis, a surgical site infection—were observed. These results suggest that cataract surgery by late-career ophthalmologists does not pose a high-priority safety hazard.
Ramjist JK, Coburn N, Urbach DR, et al. JAMA. 2018;319:1162-1163.
A privacy breach is a type of patient harm. Investigators collected a large volume of recycled paper waste from multiple hospitals and found protected health information that should have been disposed of in a more secure fashion. The authors suggest systems approaches to avoid privacy breaches related to paper medical records.
Gagliardi AR, Ducey A, Lehoux P, et al. BMJ Qual Saf. 2017;27.
Regulatory agencies rely on physician reports of adverse events associated with medical devices in order to identify safety concerns. This qualitative interview study found that most physicians who implant devices do not regularly report adverse events related to particular devices. The authors recommend that postmarketing surveillance of medical devices be redesigned to foster detection of adverse events.
Hedlund N, Beer I, Hoppe-Tichy T, et al. BMJ Open. 2017;7:e015912.
Errors in medication preparation and administration can lead to patient harm. Examining the evidence on intravenous preparation errors in hospitals, this systematic review suggests that there is significant opportunity to improve the intravenous medication preparation process.
Gagliardi AR, Lehoux P, Ducey A, et al. PLoS One. 2017;12:e0174934.
Conflict of interest between health care providers and for-profit industry represents a patient safety concern. This qualitative study examined the relationship between physicians who use implantable devices and the device manufacturer representatives. Although physicians reported being vigilant in their relationship with device representatives and recognized the potential for conflicts of interest, device representatives were often present for implantations.
Trbovich PL, Shojania KG. BMJ Qual Saf. 2017;26:350-353.
Although root cause analysis is an established strategy to investigate incidents, some have questioned its effectiveness in health care. Drawing from a recent study, this editorial suggests that robust health care investment in human factors engineering and safety science is needed to help root cause analysis achieve its full potential as an improvement mechanism. A recent Annual Perspective discussed ongoing problems with the root cause analysis process and described opportunities to improve its application in health care.
WebM&M Case February 1, 2017
… to balance the risks and benefits. … The Commentary … by Anthony C. Easty, PhD … In many industries where professionals … Rev Gen Psychol. 1998;2:175-220. [Available at] 3. Wiprud R. 30 standardized hospital admission orders. Fam Pract …
Govindarajan A, Urbach DR, Kumar M, et al. N Engl J Med. 2015;373:845-53.
The link between lack of sleep and subsequent medical errors served as an impetus for physician duty-hours reform. In trainee physicians, sleep loss is associated with attentional failures, but little is known about the relationship between attending physician performance and sleep loss. This retrospective cohort study examined outcomes of elective surgical procedures among attending surgeons who had worked after midnight on the previous night versus those who had not. The investigators found no differences in mortality, complications, or readmissions between procedures performed by surgeons with sleep loss compared to those without sleep loss, mirroring results of an earlier simulation study. This may be due to greater technical skill among attending surgeons, or the ability to cancel or postpone elective procedures as needed at times of fatigue. This study included many institutions, physicians, and procedure types, suggesting that short-term sleep deprivation might not be a high-yield safety target for attending surgeons.
Daneman N, Bronskill SE, Gruneir A, et al. JAMA Intern Med. 2015;175:1331-9.
Inappropriate antibiotic use contributes to microbial resistance for the recipient and the community. This study found increased harms related to antibiotic use among older patients living in nursing homes with higher antibiotic use compared to nursing homes with overall lower antibiotic use. These findings demonstrate the need to manage antibiotics effectively to improve the safety of all nursing home residents.