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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 33 Results
Jain A, Brooks JR, Alford CC, et al. JAMA Health Forum. 2023;4:e231197.
Algorithms are commonly used to guide clinical decision-making, but concerns have been raised regarding bias due to the use of race-based data. This qualitative analysis examined perspectives of 42 stakeholders (e.g., individuals, representatives from clinical professional societies or payers, etc.) regarding the use of race- and ethnicity-based algorithms in healthcare. Seven themes were identified, highlighting concerns regarding bias, algorithm transparency, lack of standardization regarding how race and social determinants are collected and defined, and the use of a social construct as a proxy in clinical decision-making.
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.
Urbach DR, Dimick JB, Haynes AB, et al. BMJ. 2019;366:l4700.
Checklists are a popular yet controversial strategy for improving the safety of frontline care. The authors in this commentary debate the weaknesses and strengths of checklists through a discussion of the evidence.
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.
Gomes T, Tadrous M, Mamdani MM, et al. JAMA Netw Open. 2018;1:e180217.
Opioid use can increase risk of adverse drug events, including overdoses. Researchers utilized data from the Centers for Disease Control and Prevention to examine opioid-related deaths in the United States from 2001 to 2016. During this period, opioid-related deaths increased by nearly 350%. Overdose deaths occurred more among men than women and were most prevalent in patients aged 15 to 34 years. These findings raise concern regarding the increasing proportion of deaths associated with opioid use. The authors call for targeted prevention and harm reduction efforts among young adults to address the growing opioid-related harm in this group. A PSNet perspective discussed opioid overdose as a patient safety problem.
Ramjist JK, Coburn N, Urbach DR, et al. JAMA. 2018;319:1162-1163.
A privacy breach is a type of patient harm. Investigators collected a large volume of recycled paper waste from multiple hospitals and found protected health information that should have been disposed of in a more secure fashion. The authors suggest systems approaches to avoid privacy breaches related to paper medical records.
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.
Nix M, McNamara P, Genevro J, et al. Health Aff (Millwood). 2018;37:205-212.
Learning collaboratives are multimodal interventions that are often used to implement evidence-based practices. This perspective from AHRQ scientists proposes a taxonomy to describe collaboratives' distinct elements: innovation, or the type of positive change; communication among members; duration and sustainability; and social systems, or the organization and culture of the collaborative. The authors suggest that efforts to evaluate learning collaboratives or quality improvement interventions employ this taxonomy.
Gagliardi AR, Lehoux P, Ducey A, et al. PLoS One. 2017;12:e0174934.
Conflict of interest between health care providers and for-profit industry represents a patient safety concern. This qualitative study examined the relationship between physicians who use implantable devices and the device manufacturer representatives. Although physicians reported being vigilant in their relationship with device representatives and recognized the potential for conflicts of interest, device representatives were often present for implantations.
Finkelstein Y, Macdonald EM, Gonzalez A, et al. Pediatrics. 2017;139.
Opioid-related harm is a critical patient safety priority. This case control study examined the risk of opioid overdose among children whose mothers were prescribed either opioids or nonsteroidal anti-inflammatory agents in the prior year. The cases were children aged 10 or younger who were hospitalized or died from opioid overdose, and the controls were children of the same age without overdose. Compared to the children without overdose, those who were hospitalized or died were more likely to have a mother who was prescribed opioids. Antidepressant prescription was also more common among mothers of children who experienced opioid overdose. The authors recommend specific practices for safe opioid use, including prescription of smaller quantities and secure storage of medications, which prior studies demonstrate are not yet routine. This study emphasizes the urgent need to enhance the safety of outpatient opioid use.
Govindarajan A, Urbach DR, Kumar M, et al. N Engl J Med. 2015;373:845-53.
The link between lack of sleep and subsequent medical errors served as an impetus for physician duty-hours reform. In trainee physicians, sleep loss is associated with attentional failures, but little is known about the relationship between attending physician performance and sleep loss. This retrospective cohort study examined outcomes of elective surgical procedures among attending surgeons who had worked after midnight on the previous night versus those who had not. The investigators found no differences in mortality, complications, or readmissions between procedures performed by surgeons with sleep loss compared to those without sleep loss, mirroring results of an earlier simulation study. This may be due to greater technical skill among attending surgeons, or the ability to cancel or postpone elective procedures as needed at times of fatigue. This study included many institutions, physicians, and procedure types, suggesting that short-term sleep deprivation might not be a high-yield safety target for attending surgeons.
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.
Gagliardi AR, Straus SE, Shojania KG, et al. PLoS One. 2014;9:e108585.
This qualitative study identified barriers to implementation of and adherence to a surgical checklist, including modifications to enable integration into existing practices, lack of staff engagement, and insufficient organizational support for implementation. Challenges such as these may account for mixed results from checklists in practice despite clear evidence of efficacy.
Urbach DR, Govindarajan A, Saskin R, et al. New Engl J Med. 2014;370:1029-1038.
This study examined changes in operative mortality, risk of surgical complications, length of stay, and hospital readmission rates before and after mandatory adoption of surgical safety checklists across 101 acute care hospitals in Ontario. None of the surgical outcomes improved after adoption of checklists, in stark contrast to previous observational studies that demonstrated significant improvements in surgical morbidity and mortality following checklist implementation. The risk of surgical complications and mortality prior to checklist implementation was comparable to post-implementation rates in earlier studies; checklists may not be effective when complication rates are below a threshold. In an accompanying editorial, Dr. Lucian Leape suggests that effective checklist use requires adapting the tool to local conditions, training and implementing a new and consistent workflow, and involving the entire health care team. Rather than mandating checklist adoption, he recommends that federal funding support local efforts to implement checklists. In a related piece, Dr. Atul Gawande, who co-authored a major international study that found benefit from surgical checklists and wrote a book about checklists as a safety tool, raises methodological concerns about the Ontario study.
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.