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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 - 16 of 16 Results
Griffeth EM, Gajic O, Schueler N, et al. J Patient Saf. 2023;19:422-428.
Voluntary reporting is an important tool for institutions to identify latent safety threats before they reach the patient but barriers to reporting result in low reporting rates. This quality improvement (QI) project aimed to increase near miss and error reporting within 9 intensive care units (ICU) in one healthcare system. After identifying barriers to reporting (e.g., user difficulty with online reporting system), a multi-faceted intervention was developed and implemented. Error reporting increased in 6 of 9 ICUs following implementation, with a significant increase in near miss reports.
Herasevich S, Soleimani J, Huang C, et al. BMJ Qual Saf. 2023;32:676-688.
Vulnerable populations, such as those with limited English proficiency, minoritized race or ethnicity, migrant populations, or patients qualifying for public insurance, may be at higher risk for adverse health events. In this review, researchers sought to identify frequency and causes of diagnostic error of vulnerable populations presenting to the emergency department with cardiovascular or cerebrovascular/neurological symptoms. Black patients presenting with cardiovascular symptoms had significantly higher odds of diagnostic error. Other demographic factors did not show similar associations, nor did studies of patients with cerebrovascular/neurological symptoms.
Redmond S, Barwise A, Zornes S, et al. Health Serv Insights. 2022;15:117863292211235.
Various factors – including organizational, interpersonal clinician, and patient factors – can contribute to diagnostic errors and delays. This survey of 220 clinicians explored the perceived frequency of different factors contributing to diagnostic errors or diagnostic delay. Findings suggest that system and processes, care team interactions, provider factors, cognitive factors, and patient factors were perceived to contribute to diagnostic error and delay with similar frequency.
Huang C, Barwise A, Soleimani J, et al. J Patient Saf. 2022;18:e454-e462.
Identifying and reducing diagnostic errors remains a critical patient safety concern. This prospective study asked clinicians if they perceived that a diagnostic error played a part in rapid response team activations or unplanned admissions to the intensive care unit. Clinicians reported that 18% of acute care patients experienced diagnostic errors.
Morris AH, Stagg B, Lanspa M, et al. J Am Med Inform Assoc. 2021;28:1330-1344.
Clinical decision support systems are designed to improve clinical decision-making. The authors of this commentary suggest an alternative, eActions, to reduce clinician burden and increase replicability. Dissemination and use of eActions could contribute to improved clinical care quality and research.
Barwise A, Leppin A, Dong Y, et al. J Patient Saf. 2021;17:239-248.
Diagnostic errors and delays continue to be a widespread patient safety concern in hospitalized patients. Researchers conducted focus groups with key clinician stakeholders to determine factors that contribute to diagnostic error and delay. Clinicians indicated that organizational, interactional, clinician, and patient factors all interact to cause errors and delays. These diverse factors must be considered when implementing interventions to reduce diagnostic errors and delays.
Jayaprakash N, Chae J, Sabov M, et al. Mayo Clin Proc Innov Qual Outcomes. 2019;3:327-334.
Deviations or variations in diagnostic fidelity, including diagnostic errors and delays, can lead to serious adverse events or death, yet measurement tools and reporting processes for ensuring diagnostic fidelity are underdeveloped. This single-site retrospective study found that these errors and delays can be reliably identified using EMR data, and that variations in diagnostic fidelity are linked to increased morbidity and mortality. 
Harrison AM, Siwani R, Pickering BW, et al. J Am Med Inform Assoc. 2019;26:928-933.
Providing safe and timely clinical care to patients is increasingly dependent on the presence of a functioning electronic health record (EHR) system. The impact of system downtime on patient outcomes remains unknown. In this retrospective study, researchers examined the effect of EHR downtime periods greater than an hour on adult surgical patients admitted for over 24 hours during the 6-year study period. They found a significant association between exposure to EHR downtime and increased time in the operating room as well as longer postoperative length of stay. There was no significant association with 30-day mortality.
Barwise A, Thongprayoon C, Gajic O, et al. Crit Care Med. 2016;44:54-63.
Despite widespread implementation of rapid response systems, they remain controversial. This study showed that delayed activation of rapid response was associated with worse morbidity and higher mortality compared to timely rapid response implementation. This work adds to recent data suggesting that rapid response improves patient safety.
Thongprayoon C, Harrison AM, O'Horo JC, et al. J Intensive Care Med. 2016;31:205-12.
Simulation has been advocated as a way to create a safe space to learn from error. This simulation-based study found that electronic checklists used by intensivists reduced workload and errors compared to paper checklists, adding to the evidence supporting checklist use in medical care.
Ahmed AH, Giri J, Kashyap R, et al. Am J Med Qual. 2015;30:23-30.
This systematic review found that patients who experience adverse events in intensive care units (ICUs) have significantly longer hospital and ICU stays. According to this study, the effect on mortality is less clear as the evidence linking adverse events to ICU deaths have been mixed and unreliable.
Ahmed A, Chandra S, Herasevich V, et al. Crit Care Med. 2011;39:1626-34.
The design of electronic medical record (EMR) interfaces according to human factors engineering principles is crucial to ensuring clinicians' ability to access and process data rapidly. This usability study compared a custom-designed interface with a standard off-the-shelf EMR, and found that intensive care unit physicians were able to complete patient care tasks rapidly and with greater accuracy using an interface designed with provider workflow in mind.
Pickering BW, Hurley K, Marsh B. Crit Care Med. 2009;37:2905-12.
Handovers, or handoffs, in patient care are a continued and problematic safety concern that were further elevated by The Joint Commission into a National Patient Safety Goal. Despite guidelines and past efforts to standardize the process with computerized tools, there are remaining opportunities for improvement. This study adopted a handover assessment instrument in the intensive care setting to evaluate the degree of information corruption in handover exchanges. Investigators discovered variances in information retained during a handover compared with actual facts from the medical record, and noted the potential for these variations to contribute to errors in care. The authors share their tool and advocate its use as a screening method to identify areas for improvement in the quality of handovers. A past AHRQ WebM&M case commentary discussed a fumbled handoff resulting from poor communication and lack of standardization in the process.