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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 105 Results
WebM&M Case October 31, 2023

A 2-year-old girl presented to the emergency department (ED) with joint swelling and rash following an upper respiratory infection. After receiving treatment and being discharged with a diagnosis of allergic urticaria, she returned the following day with worsening symptoms. Suspecting an allergic reaction to amoxicillin, the ED team prepared to administer methylprednisolone. However, the ED intake technician erroneously switched the patient’s height and weight in the electronic health record (EHR), resulting in an excessive dose being ordered and dispensed.

Kans J Med. 2023;June 2016:153-171.

The well-being of the healthcare workforce is known to impact care delivery. This article series draws from front-line scenarios to illustrate how a wide range or personal and professional challenges intersect to affect patient safety. Topics covered in the presented cases include work-life integration, gender discrimination and clinical mistakes.
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.
Hebballi NB, Gupta VS, Sheppard K, et al. J Patient Saf. 2022;18:e1021-e1026.
Handoffs from one care team to another present significant risks to the patient if essential patient information is not shared or understood by all team members. Stakeholders at this children’s hospital developed a structured tool for handoff between surgery and pediatric or neonatal intensive care units. Transfer of information and select patient outcomes improved, handoff time was unchanged, and attendance by all team members increased.
WebM&M Case February 23, 2022
… Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council for … after her initial evaluation for back pain, the patient’s family brought her to the emergency room because she was … Pain Med. 2019;20(4):724-735. Free full text Dowell D, Haegerich T, Chou R. No shortcuts to safer opioid …
Trockel MT, Menon NK, Rowe SG, et al. JAMA Netw Open. 2020;3:e2028111.
Fatigue among health care workers can increase the risk of errors. This large cross-sectional study of attending and house staff physicians found that sleep-related impairment was associated with increased burnout, decreased professional fulfillment, and increased self-reported clinically significant medical error. Organizational policies should focus on reducing sleep-related impairment in order to reduce harm to patients and physicians.
Stulberg JJ, Huang R, Kreutzer L, et al. JAMA Surg. 2022;157:219-220.
This study examined variation in operative technical skills among patients undergoing colorectal and non-colorectal procedures and the association with patient outcomes. Higher technical skills were significantly associated with lower rates of complications, unplanned reoperations, and death or serious morbidity. The findings suggest that this skill variation accounts for more than 25% of the variation in patient outcomes.
Klest B, Smith CP, May C, et al. Psychol Trauma. 2020;12:S159-S161.
Institutional betrayal occurs when a patient (or other individual) experiences a harm and the (health) systems compound that harm by failing to support or believe the patient. The authors of this commentary reflect on institutional betrayal during the COVID-19 pandemic and discuss examples of betrayal experienced by patients, family members, and medical providers.
Freeman K, Dinnes J, Chuchu N, et al. BMJ. 2020;368:m127.
Delays in cancer diagnosis can lead to adverse patient outcomes. This systematic review examined whether smartphone-based apps can assist patients in assessing skin cancer risk and whether they should seek medical attention for suspicious lesions. The review included nine studies evaluating six different smartphone apps; reported sensitivity and specificity varied widely across studies. The authors note limitations of the included studies, such as failure to recruit a population representative of the general population. Findings are consistent with earlier studies reporting poor performance of smartphone apps for melanoma detection. Although these apps are intended to reduce delays in diagnosis, the authors conclude they can’t be relied upon for detection of all cases of skin cancer.
Gupta A, Jain S, Croft C. JAMA. 2019;321:504-505.
The authors present a case in which an unnecessary procedure was incorrectly performed on a patient who had opted to pursue hospice care. They highlight factors contributing to the error including those related to use of the electronic health record.

Gupta M, Kaplan HC, eds. Clin Perinatol. 2017;44(3):469-728.

… … Zupancic JAF; Lee King PA; Borders AEB … M. … A. … GK … JF … D. … ME … JD … DY … JK … CL … M. … HC … T. … DM … D. … L. … … … Bose … Gupta … Kaplan … Ho … Pursley … Dukhovny … Jain … Johnson … Hagadorn … Sink … Lapcharoensap … Lee … …
Battles J, Azam I, Grady M, Reback K, eds. Rockville, MD: Agency for Healthcare Research and Quality; 2017. AHRQ Publication No. 17-0017-EF.
… the results of demonstration projects funded by AHRQ's Patient Safety and Medical Liability Reform Initiative . … health system interventions to improve safety across a range of interventions, including error disclosure … for errors. … Battles J, Azam I, Grady M, Reback K, eds. Rockville, MD: Agency for Healthcare Research and …
Rawat N, Yang T, Ali KJ, et al. Crit Care Med. 2017;45:1208-1215.
… infections . This AHRQ-funded study examined the effect of a collaborative to prevent adverse events in patients … in 56 intensive care units (ICUs) in 2 states over a 3-year period. The participating ICUs introduced a multifaceted intervention structured around the …
Mody L, Greene T, Meddings J, et al. JAMA Intern Med. 2017;177:1154-1162.
Catheter-associated urinary tract infections are considered preventable never events. This pre–post implementation project conducted in long-term care facilities employed a multimodal intervention, similar to the Keystone ICU project. This sociotechnical approach included checklists, care team education, leadership engagement, communication interventions, and patient and family engagement. The project was conducted over a 2-year period across 48 states. In adjusted analyses, this effort led to a significant decrease in catheter-associated urinary tract infections, despite no change in catheter utilization, suggesting that needed use of catheters became safer. A related editorial declares this project "a triumph" for AHRQ's Safety Program for Long-term Care.
Perspective on Safety February 1, 2017
… team training in health care. TeamSTEPPS was the result of a multi-year research and development project jointly funded … "mutual performance monitoring" challenged a physician's authority. Now physicians are more supportive of teamwork, … 2006:21-37. ISBN: 9780805848854. 2. King H, Battles J, Baker DP, et al. TeamSTEPPS: Team Strategies and Tools to …
This piece outlines 10 insights about team training in health care learned from experience with the AHRQ-supported teamwork training program, TeamSTEPPS.
Dr. Edmondson is the Novartis Professor of Leadership and Management at Harvard Business School. She is an expert on leadership, teams, and organizational learning. We spoke with her about the role of teamwork in health care and why it is becoming increasingly important.