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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 - 18 of 18 Results
Mehta SD, Congdon M, Phillips CA, et al. J Hosp Med. 2023;18:509-518.
Improving diagnosis in pediatrics is an ongoing patient safety focus. This retrospective study included 129 pediatric emergency transfer cases and examined the relationship between missed opportunity for improvement in diagnosis (MOID; determined using SaferDx) and patient outcomes. Researchers found that MOID occurred in 29% of emergency transfer cases and it was associated with higher risk of mortality and longer post-transfer length of stay.
Congdon M, Rauch B, Carroll B, et al. Hosp Pediatr. 2023;13:563-571.
Diagnostic errors in pediatrics remain a significant focus of patient safety. This study uses two years of unplanned readmissions to a children’s hospital to identify missed opportunities for improving diagnosis (MOID). Clinician decision-making and diagnostic reasoning were identified as key factors for MOID. The authors recommend that future research include larger cohorts to identify populations and conditions at increased risk for MOID-related readmissions.
Mahajan P, Grubenhoff JA, Cranford J, et al. BMJ Open Qual. 2023;12:e002062.
Missed diagnostic opportunities often involve multiple process breakdowns and can lead to serious avoidable patient harm. Based on a web-based survey of 1,594 emergency medicine physicians, missed diagnostic opportunities most frequently occur in children who present to the emergency department with undifferentiated symptoms (e.g., abdominal pain, fever, vomiting) and often involve issues related to the patient/parent-provider interaction, such as misinterpreting patient history or inadequate physical exam.
Neiswender K, Figueroa-Altmann A, Granahan K, et al. Patient Safety. 2022;4:34-38.
Shifting to a nonpunitive approach to adverse events can improve error reporting and the overall safety culture. This article describes findings from focus groups with nurses at Children’s Hospital of Philadelphia (CHOP) regarding the perceived punitive nature of the hospital’s incident reporting system and outlines how those findings informed changes to the error review process. Lessons learned highlight the importance of who performs error follow-up, skills for navigating difficult conversations, transparency, and executive-level support. Five years after these program changes were implemented, 96% of nurses surveyed felt that the new process was nonpunitive.
Mahajan P, Pai C-W, Cosby KS, et al. Diagnosis (Berl). 2021;8:340-346.
Diagnostic error is an ongoing patient safety challenge that can result in patient harm. This literature review identified a set of emergency department (ED)-focused electronic health record (EHR) triggers (e.g., death following ED visit, change in treating service after admission, unscheduled return to the ED resulting in admission) and non-EHR based signals (e.g., patient complaints, referral to risk management) with the potential to screen ED visits for diagnostic safety events.
Myers JS, Lane-Fall MB, Perfetti AR, et al. BMJ Qual Saf. 2020;29:645-654.
This study used a mixed-methods approach to characterize the impact of two academic fellowships in Quality Improvement Patient Safety (QIPS) to both graduates and their respective institutions. Students in these programs reported a positive impact of the fellowship on their careers, with nearly all being involved in QIPS administration, research or education upon graduation. Interviewed mentors also generally thought the fellowships were important and the resulting research had departmental, institutional and even national importance.
Ku BC, Chamberlain JM, Shaw KN. Pediatr Clin North Am. 2018;65:1269-1281.
Pediatric emergency care presents unique safety challenges for a vulnerable patient population. This review summarizes emergency department (ED) improvement work across the six domains of quality. The authors suggest that pediatric EDs adopt high reliability concepts to enhance collaboration and data-sharing to improve safety. They also call for increased focus on equity and patient-centeredness.
OʼConnell KJ, Shaw KN, Ruddy RM, et al. Pediatr Emerg Care. 2018;34:237-242.
Deviating from standard work processes has the potential to compromise safety. Using data from the Pediatric Emergency Care Applied Research Network, researchers analyzed incident reports determined to be process variance events. They found that 5.6% of events resulted in some form of temporary patient harm.
Benjamin L, Frush K, Shaw KN, et al. Ann Emerg Med. 2018;71:e17-e24.
Emergency departments harbor conditions that can hinder safe medication administration for pediatric patients. This policy statement identifies and prioritizes improvements such as implementing kilogram-only weight-based dosing, involving pharmacists in frontline emergency care, and utilizing computerized provider order entry and clinical decision support systems.
Blumberg SM, Mahajan P, OʼConnell KJ, et al. Pediatr Emerg Care. 2017;33:92-96.
This study analyzed a database of voluntarily reported errors to determine the types of radiologic errors encountered in a regional pediatric emergency medicine network. Radiologic errors accounted for 7% of all incident reports, of which the most common were incorrect or changed interpretations of studies. Individual errors—including clinical judgment or failure to follow established safety procedures—were judged to be more common than system factors, though only half of the incident reports described contributing causes.
Ruddy RM, Chamberlain JM, Mahajan P, et al. BMJ Open. 2015;5:e007541.
This study of incident reports from pediatric emergency departments found that a small proportion reported near misses or unsafe conditions. Common issues included medication safety, handoffs, human factors, and systems vulnerabilities, all of which are known to lead to patient harm. Prior studies have found that incident reporting is often underused. This study highlights its importance as a lens into safety problems.
Cockerham J, Figueroa-Altmann A, Foxen C, et al. Nurs Manage. 2014;45:26-31.
This commentary outlines an initiative at a 15-bed pediatric nursing unit that used quiet zones, safety huddles, and independent double checks to reduce medication errors of the type that reach the patient but neither cause harm nor require additional intervention.
Taylor AM, Chuo J, Figueroa-Altmann A, et al. Jt Comm J Qual Patient Saf. 2013;39:396-403.
Leadership WalkRounds—derived from the business management approach of "management by walking around"—are being more widely used as a means of error detection and improving safety culture. This report from a children's hospital, in which structured walkrounds by nursing and physician leaders were implemented on six units, found that this approach increased staff engagement in safety efforts, identified hidden system flaws, and resulted in the successful implementation of multiple quality improvement projects. Although this study did not specifically measure the effect of walkrounds on safety climate, prior studies have found conflicting results, which might imply that different methods of performing walkrounds may influence their success.