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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 - 20 of 43 Results
Zwaan L, Smith KM, Giardina TD, et al. Patient Educ Couns. 2023;110:107650.
Improving diagnosis and diagnostic error-related harm is a major focus within patient safety. Building on previous research, patients and patient advocates participated in a systematic prioritization exercise and prioritized ten diagnostic error reduction research priorities. Prioritized questions focused on improving care integration/coordination, communication between clinicians and patients/caregivers, improving patient reporting systems, and improved understanding of implicit bias, and underlying factors increasing risk for diagnostic errors among vulnerable patient groups. The authors note that these priorities differed more than those identified previously by diagnostic safety experts and stakeholders.
Lambert BL, Schiff GD. J Am Coll Clin Pharm. 2022;5:981-987.
In the wake of the criminal conviction of a nurse involved in a medical error, numerous organizations and institutions have warned of the negative impact it could have on learning and error disclosure. This commentary presents strategies to reduce the risk of criminal prosecution for pharmacists, including education of prosecutors and expert witnesses and minimization of overrides and workarounds.
Giardina TD, Hunte H, Hill MA, et al. J Patient Saf. 2022;18:770-778.
The 2015 National Academies of Science, Engineering, and Medicine (NASEM) report Improving Diagnosis in Healthcare defined diagnostic error as “the failure to (a) establish an accurate and timely explanation of the patient's health problem(s) or (b) communicate that explanation to the patient.” This review and interviews with subject matter experts explored how the NASEM definition of diagnostic error has been operationalized in the literature. Of the sixteen included studies, only five operationalized the definition and only three studied communicating with the patient. The authors recommend formulating a set of common approaches to operationalize each of the three components of the NASEM definition. Patients and family should be included in defining the construct of “communication to the patient.”
Samuels A, Broome ME, McDonald TB, et al. J Patient Saf Risk Manage. 2021;26:251-260.
Healthcare systems have implemented communication-and-resolution programs (CRPs) (aka CANDOR) to encourage early disclosure of adverse events. This evaluation found that CRP training participants demonstrated improvements in self-reported empathy and communication skills.
Grauer A, Kneifati-Hayek J, Reuland B, et al. J Am Med Inform Assoc. 2022;29:909-917.
J Am Med Inform Assoc … Problem lists , while an important … health records (EHR) (medication ordered lacking a corresponding problem on the problem list) in two different … needs further study. … Grauer A, Kneifati-Hayek J, Reuland B, et al. Indication alerts to improve problem list …
Galanter W, Eguale T, Gellad WF, et al. JAMA Netw Open. 2021;4:e2117038.
One element of conservative prescribing is minimizing the number of medications prescribed. This study compared the number of unique, newly prescribed medications (personal formularies) of primary care physicians across four health systems. Results indicated wide variability in the number of unique medications at the physician and institution levels. Further exploration of personal formularies and core drugs may illuminate opportunities for safer and more appropriate prescribing.
Fisher KA, Smith KM, Gallagher TH, et al. Jt Comm J Qual Patient Saf. 2020;46:261-269.
This article evaluates the implementation of the We Want to Know program, which encourages hospitalized patients to speak up about breakdowns in care. Over a three-year period at one large, community hospital, the program interviewed over 4,600 patients and identified 822 (17.6%) who experienced a breakdown in care. Of those, 66.5% identified harm associated with the incident and 61.9% had spoken to someone at the hospital about it. Stakeholders (e.g., nurses, nurse managers, physicians, hospital administrators and leadership) found the program reports provided timely, actionable information and allowed for real-time responses and resolutions. Concerns cited by stakeholders included overlap with exiting patient safety reporting efforts, high level of effort and resources required, ensuring adequate responses.
Hatlie MJ, Nahum A, Leonard R, et al. Jt Comm J Qual Patient Saf. 2020;46:158-166.
Effectively engaging patients and family members is a necessary prerequisite to providing effective patient- and family-centered care. This article describes lessons learned during the six years after a large regional health care system in the U.S. established a systemwide infrastructure of patient and family advisory councils (PFACs) to help improve the quality, safety, and experience of care it provides. Successful elements are described, and the authors conclude that an openness to continuous improvement and adaptation was particularly important.
Lambert BL, Galanter W, Liu KL, et al. BMJ Qual Saf. 2019;28:908-915.
Look-alike and sound-alike (LASA) drugs are a well-established source of medication errors that place patients at risk for adverse drug events. Prior research has shown that these medications can be automatically identified using diagnostic codes at the time of electronic prescribing. Using electronic health record data on medication orders and diagnostic claims data from a single academic medical center as well as data on medication indications, researchers developed an algorithm to identify LASA prescribing errors. Although the algorithm was able to identify LASA prescribing errors that may not have been found by other means, the positive predictive value was 12.1% and the false-positive rate was greater than 75%. The authors advocate for further research to improve specificity and sensitivity of this approach. A past WebM&M commentary discussed a case involving the mix-up of two medications with similar names.
Salazar A, Karmiy SJ, Forsythe KJ, et al. Am J Health Syst Pharm. 2019;76:970-979.
Medication errors occur frequently in the outpatient setting and can lead to patient harm. A common scenario is one in which a patient is prescribed multiple medications, does not know what each one is for, and takes them incorrectly. Medication safety experts have advocated that prescribers include indications on prescription labels to enable patients and pharmacists to check the bottle in order to remember a medication's purpose. Investigators examined more than 4 million outpatient prescriptions from a single institution and found that only 7.4% of prescriptions included an indication. Medications for symptoms like pain, nausea, and anxiety were much more likely to have indications than medications for chronic diseases. Internal medicine physicians, whose patients are more likely to take multiple medications, wrote indications 6% of the time. A PSNet perspective explored how community pharmacists can use medication indications and other tools to ameliorate medication-related harm.
Adelman JS, Applebaum JR, Schechter CB, et al. JAMA. 2019;321:1780-1787.
Having multiple patient records open in the electronic health record increases the potential risk of wrong-patient actions. This randomized trial tested two different electronic health record configurations: one allowed up to four patient records to be open at a time, and the other allowed only one to be open. Among the 3356 clinicians with nearly 4.5 million order sessions, there were no significant differences in wrong-patient orders. However, the investigators noted that clinicians in the multiple records group placed most orders with just one record open. A post hoc analysis determined that the rate of errors increased when orders were placed with multiple records open. A related editorial highlights the tradeoffs between safety and efficiency and argues for examining the context of the two configurations, including throughput and clinician satisfaction. A previous PSNet perspective discussed assessing and improving the safety of electronic health records.
Thomas NJ, Lynam AL, Hill A, et al. Diabetologia. 2019;62:1167-1172.
This population-based cohort study sought to determine whether patients with adult-onset type 1 diabetes are misdiagnosed. Investigators found that 21% of the patients diagnosed with type 2 diabetes after age 30 actually had type 1 diabetes. They caution clinicians to carefully consider type 1 diabetes in adults requiring insulin.
Smith KM, Smith LL, (Jack) Gentry JC, et al. J Patient Saf Risk Manag. 2018;24:83-89.
J Patient Saf Risk Manag … Appropriate response to patient … harm is important. This commentary describes a seven-element approach to resolving family and patient … a communication-and-resolution program community. … Smith KM, Smith LL, Gentry JC, Mayer DB. J Patient Saf Risk …
Gallagher TH, Mello MM, Sage WM, et al. Health Aff (Millwood). 2018;37:1845-1852.
Communication-and-resolution programs are designed to build healing relationships, offer appropriate compensation, and facilitate organizational learning after a harmful medical error. Although some success has been achieved, communication-and-resolution programs have yet to be widely implemented across the health system. This commentary discusses policy, safety outcome evidence, monetary, and program design weaknesses as prominent barriers to wide-scale implementation. The authors recommend aligning the programs to foundational concepts of safety and patient-centeredness to help drive progress.
Schiff G, Mirica MM, Dhavle AA, et al. Health Aff (Millwood). 2018;37:1877-1883.
Although electronic prescribing has been shown to reduce prescribing errors, the impact on adverse drug events remains less certain. Overriding of drug–drug interaction alerts and inclusion of free-text notes that contain inaccurate information within electronic prescriptions suggests that safe prescribing requires more than an electronic system. To improve the safety of electronic prescribing, the authors make several broad recommendations. They suggest including drug indications on prescriptions, ensuring a readily available and accurate medication list, notifying pharmacies when previously prescribed medications are canceled, using standard prescription instructions, improving decision support, and promoting consideration of nondrug options. A previous WebM&M commentary discussed an incident involving an electronic prescribing error. The Moore Foundation provides free access to this article.
Fisher K, Smith KM, Gallagher TH, et al. BMJ Qual Saf. 2019;28:190-197.
Patients are frequently encouraged to engage with health care providers as partners in safety by speaking up and sharing their concerns. Although research has shown that patients and family members sometimes identify safety issues that might otherwise go unnoticed, they may not always be willing to speak up. In this cross-sectional study involving eight hospitals, researchers used postdischarge patient survey data to understand patients' comfort in voicing concerns related to their care. Almost 50% of the 10,212 patients who responded to the survey reported experiencing a problem during hospitalization, and 30% of those patients did not always feel comfortable sharing their concerns. An Annual Perspective summarized approaches to engaging patients and caregivers in safety efforts.
Schiff G, Martin SA, Eidelman DH, et al. Ann Intern Med. 2018;169:643-645.
Safe diagnosis is a complex challenge that requires multidisciplinary approaches to achieve lasting improvement. The authors worked with a multidisciplinary panel to build a 10-element framework outlining steps that support conservative diagnosis. Recommendation highlights include a renewed focus on history-taking and physician examination, as discussed in a PSNet perspective. They also emphasize the importance of continuity between clinicians and patients to build trust and foster timely diagnosis. Taken together with recommendations for enhanced communication between specialist and generalist clinicians and more judicious use of diagnostic testing, this report is a comprehensive approach to reducing overdiagnosis and overtreatment.
Kannampallil TG, Manning JD, Chestek DW, et al. J Am Med Inform Assoc. 2018;25:739-743.
Opening multiple patients' charts in the electronic medical record simultaneously may increase the risk of wrong-patient orders, a known patient safety hazard. Researchers analyzed intercepted wrong-patient medication orders in an emergency department over a 6-year period and found no significant reduction when the maximum number of charts allowed to be open at the same time decreased from 4 to 2. Similarly, there was no significant increase when the maximum number of charts permitted to be open simultaneously increased from 2 to 4.