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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 - 9 of 9 Results
Michelson KA, Bachur RG, Rangel SJ, et al. JAMA Netw Open. 2024;7:e2353667.
Racial and ethnicity disparities can contribute to biases which can negatively impact health outcomes and patient safety. This retrospective cohort study including 93,136 children across nearly 1,000 EDs in the US between 2014 and 2019 found that Asian and Pacific Islander, Black, and Hispanic patients were more likely to experience delayed diagnosis of appendicitis and complications of appendicitis compared to White patients.
Michelson KA, Bachur RG, Grubenhoff JA, et al. J Emerg Med. 2023;65:e9-e18.
Missed diagnosis in the emergency department can result in unplanned hospitalization due to complications from worsening symptoms. In this study, pediatric patients with and without missed emergency department diagnosis were compared to determine differences in outcomes and hospital utilization. Children with missed diagnosis of appendicitis or new-onset diabetic ketoacidosis experienced more complications, hospital days and readmissions; there was no difference for sepsis diagnosis.
Milliren CE, Bailey G, Graham DA, et al. J Patient Saf. 2022;18:e741-e746.
The Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare & Medicaid Services (CMS) use a variety of quality indicators to measure and rank hospital performance. In this study, researchers analyzed the variance between AHRQ pediatric quality indicators and CMS hospital-acquired condition indicators and evaluated the use of alternative composite scores. The researchers identified substantial within-hospital variation across the indicators and could not identify a single composite measure capable of capturing all of the variance observed across the broad range of outcomes. The authors call for additional research to identify meaningful approaches to performance ranking for children’s hospitals.
Michelson KA, Reeves SD, Grubenhoff JA, et al. JAMA Netw Open. 2021;4:e2122248.
Diagnostic errors, including delayed diagnoses, continue to be a patient safety concern. This case-control study of children treated at five pediatric emergency departments explored the preventability of delayed diagnosis of pediatric appendicitis and associated outcomes. Researchers estimated that 23% of delayed diagnosis cases were likely to be preventable and that delayed diagnosis led to longer hospital length of stay, higher perforation rates, and additional surgical procedures.
DeCourcey DD, Silverman M, Chang E, et al. Pediatr Crit Care Med. 2017;18:370-377.
Medication reconciliation is critical to safe medication use. This prospective cohort study identified high rates of unintentional medication discrepancies among hospitalized children and young adults. The authors conclude that current medication reconciliation practices are inadequate to ensure medication safety.
Raphael BP, Murphy M, Gura KM, et al. Nutr Clin Pract. 2016;31:654-658.
Medication compounding is prone to dosing errors. This study found that the majority of reviewed home parenteral nutrition preparations, which must be individually compounded based on caloric and nutrient needs, had at least one discrepancy between the formulation prescribed and dispensed. The authors recommend routine reconciliation of home parenteral nutrition compounds with prescriptions to prevent errors.
Fleming-Dutra KE, Hersh AL, Shapiro DJ, et al. JAMA. 2016;315:1864-1873.
More than 12% of all outpatient visits in the United States in 2010–2011 resulted in an antibiotic prescription, of which approximately 30% were inappropriate, according to this population-based analysis. Inappropriate antibiotic prescribing increases the risk of antibiotic-resistant infections and is a recognized patient safety risk. A WebM&M commentary discusses catastrophic complications resulting from an inappropriate antibiotic prescription for sinusitis.
Norton EK, Singer SJ, Sparks W, et al. J Patient Saf. 2016;12:44-50.
Implementation of surgical checklists remains incomplete, despite evidence supporting their use. This survey study revealed that clinicians had positive perceptions of checklists 1 year after implementation, suggesting that resistance to checklist use is not a major barrier in this setting.
Mansah M, Griffiths R, Fernandez R, et al. J Patient Saf. 2014;10:146-53.
This retrospective review of incident reports at a tertiary care hospital revealed that errors related to falls, medication management, and clinical care were the most common adverse events among patients aged 65 years and older. This finding mirrors prior studies suggesting that older adults experience high rates of harm while receiving medical treatment.