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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 - 9 of 9 Results
Macrae C, Stewart K. BMJ. 2019;364:l1039.
Principles from high-risk industries can be applied to safety improvement efforts in health care, but complexities unique to medicine can make translating these approaches challenging. This commentary highlights examples from aviation to illustrate both successes and areas where improvement is still elusive.
Harrison R, Sharma A, Lawton R, et al. J Patient Saf. 2021;17:e1633-e1637.
… Journal of patient safety … J Patient Saf … Mentors can serve as coaches to help improve … clinician performance. This study examined whether having a professional mentor affected physicians' involvement in an … event or near miss, and nearly half described having a mentor. Physicians with mentors were about 10% less likely …
Jordan KP, Timmis A, Croft P, et al. BMJ. 2017;357:j1194.
Missed and delayed diagnoses are an increasingly recognized patient safety problem. A common undiagnosed symptom in outpatient medicine is chest pain. This retrospective cohort study compared outcomes for three groups of patients with chest pain: those whose pain remained undiagnosed after 6 months versus those diagnosed with either coronary artery disease or a verified noncardiac cause of chest pain. Only a minority of the undiagnosed patients underwent diagnostic testing for coronary artery disease. The highest risk of myocardial infarction was in patients with diagnosed coronary artery disease, but undiagnosed patients were more likely to have a myocardial infarction than those with verified noncardiac disease. The authors conclude that patients without a timely diagnosis merit further evaluation to reduce the risk of cardiovascular events.
Wu J, Gale CP, Hall M, et al. Eur Heart J Acute Cardiovasc Care. 2018;7:139-148.
Although diagnostic errors represent an important cause of preventable patient harm as well as a common and expensive source of malpractice litigation, they have received little attention until recently. Misdiagnosis or delayed diagnosis of common conditions, such as acute myocardial infarction (AMI), occurs frequently. In this study, researchers sought to assess whether a correct initial diagnosis had an impact on the mortality of patients with AMI. They looked at a cohort of patients over 9 years across 243 acute care hospitals in England and Wales with discharge diagnoses of ST-elevation myocardial infarction and non–ST-elevation myocardial infarction. The authors concluded that almost a third of patients were initially misdiagnosed and that this was associated with increased mortality. A PSNet Annual Perspective discussed recent advances in thinking about diagnostic error.
Power M, Stewart K, Brotherton A. Clin Risk. 2012;18:163-169.
This commentary describes the design and initial test of a large-scale initiative to track incidents involving pressure ulcers, falls, urinary infections in patients with catheters, and venous thromboembolism in the National Health Service.