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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 - 17 of 17 Results
Li W, Stimec J, Camp M, et al. J Emerg Med. 2022;62:524-533.
While pediatric musculoskeletal radiograph misinterpretations are rare, it is important to know what features of the image area are associated with false-positive or false-negative diagnoses. In this study, pediatric emergency medicine physicians were asked to interpret radiographs with and without known fractures. False-positive diagnosis (i.e., a fracture was identified when there was none) were reviewed by an expert panel to identify the location and anatomy most prone to misdiagnosis.
Henderson M, Han F, Perman C, et al. Health Serv Res. 2022;57:192-199.
With the goal of improving allocation of scarce care coordination resources in primary care, this study utilized Medicare fee-for-service claims data to identify risk factors to identify individuals at risk of future avoidable hospital events. Risk factors in six domains were identified: diagnosis, pharmacy utilization, procedure history, prior utilization, social determinants of health, and demographic information.
WebM&M Case November 30, 2021

A 32-year-old pregnant woman presented with prelabor rupture of membranes at 37 weeks’ gestation. During labor, the fetal heart rate dropped suddenly and the obstetric provider diagnosed umbilical cord prolapse and called for an emergency cesarean delivery. Uterine atony was noted after delivery of the placenta, which quickly responded to oxytocin bolus and uterine massage.

WebM&M Case November 25, 2020
… … The Commentary … By Gary S. Leiserowitz, MD, MS and Herman Hedriana, MD Necrotizing fasciitis (NF) encompasses a … of print. PMID: 32987224. Wang, Y. Y., Wan, Q. Q., Lin, F., Zhou, W. J., & Shang, S. M. (2017). Interventions to … care. BMJ Quality & Safety 2004;13:i85-i90. Pope, Barbara B. RN, CCNS, CCRN, MSN; Rodzen, Lisa RN, BSN; Spross, Gene …
WebM&M Case July 29, 2020

A 28-year-old woman arrived at the Emergency Department (ED) with back pain, bloody vaginal discharge, and reported she had had a positive home pregnancy test but had not received any prenatal care and was unsure of her expected due date. The ED intern evaluating the patient did not suspect active labor and the radiologist remotely reviewing the pelvic ultrasound mistakenly identified the fetal head as a “pelvic mass.” Four hours later, the consulting OB/GYN physician recognized that the patient was in her third trimester and in active labor.

Barstow L, Herman E, Phillips H, et al. Ped Emerg Care. 2018;36:e393-e396.
Prescribing errors occur frequently among hospitalized pediatric patients and can compromise safety. This retrospective study found that 776 of 1934 antibiotic prescriptions written for pediatric patients discharged from the emergency department over a 1-year period contained a dosing error.
Yeung S, Downing L, Fei-Fei L, et al. New Engl J Med. 2018;378:1271-1273.
Artificial intelligence technologies can support diagnostic decision-making. This commentary discusses application of deep learning tools to create visual cues to track deviations in activities to flag areas of improvement. Although early in its development, the authors outline the potential of this technology in clinical care and review early efforts employed to enhance hand hygiene.
Herman B, Fei F. Mod Healthc. December 2, 2016.
Underserved communities face challenges to receiving high quality care. This magazine article reports on pervasive problems in the Indian Health Service (IHS) that result in an unsafe care system, such as chronic lack of funding and high workforce turnover. The article includes insights from tribe advocates seeking improvement in the IHS.
Custer PL, Fitzgerald ME, Herman DC, et al. Ophthalmology. 2016;123:S40-5.
Efforts to reduce medical errors in ophthalmology often focus on cataract surgery, a high-volume procedure. This commentary explores how a culture of safety affects ophthalmic care, including its influence on error disclosure, teamwork, and failure analysis. The authors also describe initiatives that integrate core safety concepts into professional development programs for the specialty.
Shields LE, Wiesner S, Klein C, et al. Am J Obstet Gynecol. 2016;214:527.e1-527.e6.
Many organizations, including The Joint Commission and the National Partnership for Maternal Safety, recommend the use of early warning systems when treating maternity patients. This prospective study evaluated a maternal early warning trigger tool that was internally developed and piloted at six hospitals within a large health system. The tool was pathway specific and targeted the four most common causes of maternal morbidity: hemorrhage, preeclampsia, sepsis, and cardiac dysfunction. Severe maternal morbidity, as defined by the Centers for Disease Control and Prevention, and composite morbidity significantly decreased following implementation of this tool compared with both baseline rates and control hospitals. In 2010, The Joint Commission issued a sentinel event alert on preventing maternal death.
Schmidt HG, Van Gog T, Schuit SC, et al. BMJ Qual Saf. 2017;26:19-23.
As diagnostic errors continue to rise to the forefront of patient safety, identifying specific drivers and target areas will be critical to improving diagnosis. To examine how patients' disruptive behaviors may provoke emotional responses in physicians that contribute to diagnostic inaccuracy, researchers in the Netherlands had 63 family practice residents evaluate 6 clinical vignettes that presented patients as either difficult or neutral. For patients that displayed distressing behaviors, physicians' mean diagnostic accuracy was significantly lower, even though they spent the same amount of time contemplating the diagnosis. In the related study, 74 internal medicine residents were randomized to 8 clinical vignettes that were identical except for whether the patient displayed difficult or neutral behaviors. Once again, mean diagnostic scores were significantly lower for difficult compared to neutral patients' vignettes, and time spent reaching a diagnosis was similar across groups. Physicians recalled fewer clinical findings and more behaviors from difficult-patient vignettes. This finding suggests that the devotion of mental resources to dealing with behaviors may hinder clinical processing. A recent PSNet perspective reviewed emerging progress on addressing diagnostic errors.
Sarrechia M, Van Gerven E, Hermans L, et al. J Adv Nurs. 2013;69:278-85.
A considerable body of literature documents widespread variations in outcomes for patients hospitalized at different hospitals for similar conditions. Care pathways are intended to improve outcomes by standardizing use of evidence-based practices, and a surgical pathway was recently shown to markedly reduce both complications and postoperative mortality. However, this survey of obstetric care pathways for normal deliveries at Belgian hospitals found that the 17 pathways analyzed varied widely and did not consistently apply evidence-based practices to prevent postpartum complications. A devastating series of preventable complications during delivery, which led to the death of an infant, is discussed in this classic commentary, and lessons learned from the case have been incorporated into a video widely used for teaching purposes.
Rodriguez-Paz JM, Mark L, Herzer KR, et al. Anesth Analg. 2009;108:202-10.
This study describes the use of a systematic process, similar to a failure mode effects analysis, that anticipates potential safety issues before introducing a new intraoperative radiation therapy. The authors suggest their process can be applied to the introduction of any new technologies, treatments, or procedures.