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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 - 18 of 18 Results
Doctor JN, Stewart E, Lev R, et al. JAMA Netw Open. 2023;6:e2249877.
Research has shown that prescribers who are notified of a patient’s fatal opioid overdose will decrease milligram morphine equivalents (MME) up to 3 months following notification as compared to prescribers who are not notified. This article reports on the same cohort’s prescribing behavior at 4-12 months. Among prescribers who received notification, total weekly MME continued to decrease more than the control group during the 4-12 month period.
Keller SC, Caballero TM, Tamma PD, et al. JAMA Netw Open. 2022;5:e2220512.
… to November 2020, 389 ambulatory practices participated in a quality improvement project using the Agency for Healthcare … that completed the program and submitted data showed a significant decrease of antibiotic prescribing for acute …
Chua K-P, Fischer MA, Linder JA. BMJ. 2019;364:k5092.
Prescribing unnecessary antibiotics increases the risk of resistant infections and can lead to patient harm. In this cross-sectional study, researchers found that 23% of the 15,455,834 outpatient antibiotic prescriptions filled among a cohort of 19.2 million patients over a 1-year period were consistent with inappropriate prescribing.
Vaughn VM, Linder JA. BMJ Qual Saf. 2018;27:583-586.
Despite the benefits of health information technology, such systems can have detrimental effects on clinician decision-making. This commentary discusses how electronic health record design can contribute to inappropriate test ordering. The author recommends that influences such as heuristics and social norms be considered when developing electronic health record systems to improve care.
Shahian DM, Normand S-LT, Friedberg MW, et al. Ann Surg. 2016;264:36-8.
Public ratings of hospital quality and safety data may not always provide the best information for patients and clinicians. This commentary discusses problems with the existing set of patient safety metrics and suggests that measurement approaches need to be improved to enhance transparency and decision making.
Perspective on Safety February 1, 2016
… Second, some have warned that the United States faces a looming shortage of physicians. Better professional … the same physicians who reported the original problem. … Mark Friedberg, MD, MPP … Senior Natural Scientist RAND … 2012;172:31-32. [go to PubMed] 2. Sinsky CA, Willard-Grace R, Schutzbank AM, Sinsky TA, Margolius D, Bodenheimer T. In …
This piece highlights the importance of focusing on physician professional satisfaction as a way to determine potential patient safety hazards and improve health care quality.
Semigran HL, Linder JA, Gidengil C, et al. BMJ. 2015;351:h3480.
There is concern around patients' increasing use of online symptom checkers for medical information and health care recommendations. This study used standardized patient cases to examine the accuracy of 23 publicly available services which aim to provide a diagnosis for specific symptoms or give a triage recommendation. The online services listed the correct diagnosis first in about one-third of instances and listed the correct diagnosis in the top 20 possible diagnoses in more than half of cases. Concerningly, symptom checkers provided varying triage recommendations, with appropriate advice ranging from 33% to 78% of evaluations. Certain symptom checkers encouraged users to seek care in cases where self-care was reasonable. These data do not support the use of online symptom checkers for diagnosis or triage and argue for use of simulation approaches to evaluate digital health tools. A related editorial calls for evidence on the actual use of such symptom checkers, followed by randomized trials to evaluate the effect on outcomes and costs prior to their widespread implementation.
Linder JA, Doctor JN, Friedberg MW, et al. JAMA Intern Med. 2014;174:2029-31.
Unnecessary prescribing of antibiotics for viral conditions can pose patient safety risks. This study found that primary care physicians are more likely to prescribe antibiotics inappropriately toward the end of their clinic session (late morning or late afternoon), which likely represents clinicians' decision fatigue.
Persell SD, Bailey SC, Tang J, et al. Am J Med. 2010;123:182.e9-182.e15.
… The American journal of medicine … Am J Med … Medication reconciliation discrepancies—differences … in this study. These discrepancies were associated with a higher likelihood of uncontrolled hypertension. Prior …
Rothschild JM, Woolf S, Finn KM, et al. Jt Comm J Qual Patient Saf. 2008;34:417-25, 365.
Widespread implementation of rapid response teams (RRTs) has been spurred by endorsements from prominent organizations and a Joint Commission National Patient Safety Goal. However, the evidence on effectiveness of such teams is mixed, although recent single-institution studies have shown impressive improvements in clinical outcomes. This study found that implementation of an RRT at an academic medical center did not improve clinical outcomes over a 6-month follow-up period. This study is one of the few to evaluate the effectiveness of teams led by resident physicians and nurses, in contrast with other studies evaluating RRTs led by critical care physicians.
Linder JA, Ma J, Bates DW, et al. Arch Intern Med. 2007;167:1400-5.
This cross-sectional study found that outpatient practices' use of an electronic health record (EHR) was not associated with higher quality care. The authors posit several reasons for this finding, including the possibility that EHRs were not implemented as fully as at benchmark institutions, or lacked decision support.