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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
Michelson KA, Bachur RG, Grubenhoff JA, et al. J Emerg Med. 2023;65:e9-e18.
Missed diagnosis in the emergency department can result in unplanned hospitalization due to complications from worsening symptoms. In this study, pediatric patients with and without missed emergency department diagnosis were compared to determine differences in outcomes and hospital utilization. Children with missed diagnosis of appendicitis or new-onset diabetic ketoacidosis experienced more complications, hospital days and readmissions; there was no difference for sepsis diagnosis.
Michelson KA, Reeves SD, Grubenhoff JA, et al. JAMA Netw Open. 2021;4:e2122248.
Diagnostic errors, including delayed diagnoses, continue to be a patient safety concern. This case-control study of children treated at five pediatric emergency departments explored the preventability of delayed diagnosis of pediatric appendicitis and associated outcomes. Researchers estimated that 23% of delayed diagnosis cases were likely to be preventable and that delayed diagnosis led to longer hospital length of stay, higher perforation rates, and additional surgical procedures.
DeCourcey DD, Silverman M, Chang E, et al. Pediatr Crit Care Med. 2017;18:370-377.
Medication reconciliation is critical to safe medication use. This prospective cohort study identified high rates of unintentional medication discrepancies among hospitalized children and young adults. The authors conclude that current medication reconciliation practices are inadequate to ensure medication safety.
Raphael BP, Murphy M, Gura KM, et al. Nutr Clin Pract. 2016;31:654-658.
Medication compounding is prone to dosing errors. This study found that the majority of reviewed home parenteral nutrition preparations, which must be individually compounded based on caloric and nutrient needs, had at least one discrepancy between the formulation prescribed and dispensed. The authors recommend routine reconciliation of home parenteral nutrition compounds with prescriptions to prevent errors.