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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 25 Results
Redelmeier DA, Shafir E. Med Decis Making. 2023;43:183-190.
Premature closure occurs when clinicians accept a diagnosis before it has been confirmed and alternative diagnoses have been explored and can lead to missed diagnosis. In this study, participants (including both health care professionals and community members) were provided one of five scenarios describing a hypothetical patient with symptoms suggestive of COVID-19 in the presence or absence alternative diagnosis (e.g., COVID-19 symptoms and the presence or absence of a positive flu test). Findings suggest that bias can lead individual to overlook the likelihood of COVID-19 when an alternative diagnosis is present.
Redelmeier DA, Etchells EE, Najeeb U. J Hosp Med. 2022;17:405-409.
… healthcare workers to speak up about safety concerns is a core tenant of safety culture. This article outlines how … up behavior and approaches to mitigating these pitfalls. … Redelmeier DA, Etchells EE, Najeeb U. Honest communication and social asymmetries inside a hospital: pitfalls for clinicians. J Hosp Med. …
Lapointe-Shaw L, Bell CM, Austin PC, et al. BMJ Qual Saf. 2020;29:41-51.
Medication reconciliation is an important component of strategies for preventing adverse events after hospital discharge. Studies show that comprehensive medication interventions (including medication reconciliation) by hospital-based pharmacists can reduce adverse events and readmissions in older patients. This Canadian study sought to evaluate whether medication reconciliation and education by community pharmacists could also achieve the same aims for recently discharged patients. This nonrandomized study used propensity score analysis to evaluate outcomes of patients who received medication reconciliation and review of medication adherence performed by community pharmacists during a dedicated visit. Researchers found that patients receiving the service had a reduction in readmissions and death. The magnitude of benefit was small overall, but it was larger in patients who were filling a new prescription for a high-risk medication. Although the nonrandomized design precluded firmer conclusions, this study indicates that community-based medication reconciliation and review may be a promising strategy for reducing adverse events after discharge.
Liu JJ, Rotteau L, Bell CM, et al. BMJ Qual Saf. 2019;28:894-900.
When engaged in safety efforts, patients may identify hazards not detected through other means. Patient relations personnel interviewed in this qualitative study revealed that patient complaints rarely lead to organization-wide change. An Annual Perspective described how patients can effectively coengineer safer health care systems.
Campbell RJ, El-Defrawy SR, Gill SS, et al. JAMA Ophthalmol. 2019;137:58-64.
Prior work has demonstrated that surgical outcomes differ depending on individual practitioner skill, and concerns have been raised regarding the need to assess skills of aging physicians. This study examined whether cataract surgery outcomes differ for late-career ophthalmologists, defined as those who completed medical school at least 25 years ago, compared to mid-career ophthalmologists, who completed medical school 15 to 25 years ago. This secondary data analysis of all single-eye cataract surgeries performed in Ontario between 2009 and 2013 found that almost 30% of procedures were performed by late-career practitioners. Overall, adverse surgical events did not differ by career stage, although very small increases in risk of two specific complications—dropped lens fragment and endophthalmitis, a surgical site infection—were observed. These results suggest that cataract surgery by late-career ophthalmologists does not pose a high-priority safety hazard.
Gagliardi AR, Ducey A, Lehoux P, et al. BMJ Qual Saf. 2017;27.
Regulatory agencies rely on physician reports of adverse events associated with medical devices in order to identify safety concerns. This qualitative interview study found that most physicians who implant devices do not regularly report adverse events related to particular devices. The authors recommend that postmarketing surveillance of medical devices be redesigned to foster detection of adverse events.
Saposnik G, Redelmeier DA, Ruff CC, et al. BMC Med Inform Decis Mak. 2016;16:138.
Cognitive bias can contribute to diagnostic error, leading to delays in treatment and unnecessary harm to patients. Consistent with prior research, this systematic review found that multiple types of cognitive bias are associated with diagnostic mistakes and inadequate medical management of patients.
Daneman N, Bronskill SE, Gruneir A, et al. JAMA Intern Med. 2015;175:1331-9.
Inappropriate antibiotic use contributes to microbial resistance for the recipient and the community. This study found increased harms related to antibiotic use among older patients living in nursing homes with higher antibiotic use compared to nursing homes with overall lower antibiotic use. These findings demonstrate the need to manage antibiotics effectively to improve the safety of all nursing home residents.
Stall NM, Fischer HD, Wu F, et al. Medicine (Baltimore). 2015;94:e899.
This study established that unintentional medication discontinuation upon nursing home admission decreased over time, though this improvement could not be attributed to accreditation requirements for medication reconciliation or any other specific intervention. This study highlights the challenge of attributing safety improvements to specific policy or practice changes.
Dhalla IA, O'Brien T, Morra D, et al. JAMA. 2014;312:1305-12.
Preventing hospital readmissions has been a major health system priority for several years. Although recent data indicates that readmissions in adult patients are decreasing slightly, the approaches individual hospitals or health systems should use to prevent readmissions remain unclear. This randomized controlled trial evaluated the effect of a postdischarge virtual ward where patients received postdischarge care from a multidisciplinary team that met daily to review the patient's progress, conduct home visits, arrange home services, and coordinate care with the patient's primary physicians. Patients were admitted to the virtual ward for a mean of 35 days after discharge and received 3 home visits on average during that time. Despite the intensity of the intervention, there was no effect on 30-day readmissions or any other clinical outcome compared to usual postdischarge care. Another recent randomized trial found that a similarly intensive intervention did not reduce readmissions in a vulnerable elderly patient population. The authors of this study note that difficulty in communicating with primary care physicians, exacerbated by the lack of an integrated electronic medical record, may have contributed to the failure of the virtual ward at preventing readmissions.
Jeffs L, Hayes C, Smith O, et al. Eval Health Prof. 2014;37:366-78.
An organization-wide patient safety program consisting of open access online educational modules, an online forum for communication, and a reward system, led to a significant increase in voluntary patient safety event reporting. The largest uptick was seen in near miss reporting, which nearly doubled following the intervention.
Soong C, Daub S, Lee J, et al. J Hosp Med. 2013;8:444-9.
The hospital discharge process is often disorganized and lacks standardization. As a result, adverse events after hospital discharge are disturbingly common. This study reports on a multidisciplinary, collaborative effort—involving hospitalists, primary care physicians, home care and bedside nurses, and pharmacists—to develop a standardized hospital discharge checklist. The resulting tool is designed to be used daily during hospitalization as part of interprofessional discharge planning rounds and consists of seven domains that address key aspects of the hospital-to-home transition, including medication reconciliation and communication between physicians. Further validation will be required to demonstrate that this checklist can prevent adverse events in broad hospitalized patient populations.
Bell CM, Brener SS, Gunraj N, et al. JAMA. 2011;306:840-7.
Care transitions are a vulnerable time for patients, particularly following hospitalization when discharge communication, pending tests, and medication reconciliation are all known challenges. This study analyzed a population-based data set containing both hospitalization and outpatient prescription records to identify the incidence of potentially unintentional medication discontinuation among patients 66 years or older. Analyzing nearly 400,000 patients, investigators found high rates of medication discontinuation ranging from 5% to 19% across 5 evidence-based medication classes (e.g., lipid lowering, thyroid replacement, antiplatelet agents) for hospitalized patients. Admission to the ICU was associated with an even greater risk of medication discontinuation. While some medication discontinuation is not surprising in the setting of a critical illness that may create new contraindications to preexisting medications, both this study and an accompanying editorial [see link below] raise appropriate concern about carefully reconciling chronic disease medications following hospitalization. A past AHRQ WebM&M conversation and perspective discussed the challenges and opportunities for improving care transitions.
Gurwitz JH, Field T, Rochon P, et al. J Am Geriatr Soc. 2008;56:2225-33.
… cluster-randomized trial evaluated the effectiveness of a computerized provider order entry (CPOE) system at … only limited decision support capabilities. An AHRQ WebM&M commentary discusses a case of a medication error associated with warfarin use at …
van Walraven C, Taljaard M, Bell CM, et al. CMAJ. 2008;179:1013-8.
… that information from the previous visit was available at a subsequent visit only 22% of the time. Factors associated … with information being available included care by a family physician and whether that physician was treating … information exchange between providers. A past AHRQ WebM&M perspective discussed care transitions associated with …