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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 - 8 of 8 Results
Patient Safety Innovation March 29, 2023

Medication reconciliation is a common strategy to improve patient safety but is complex and time consuming. Three academic medical centers developed and implemented a risk stratification tool so limited pharmacist resources could be allocated to patients with the highest likelihood of medication adverse events.

Mahajan P, Pai C-W, Cosby KS, et al. Diagnosis (Berl). 2021;8:340-346.
Diagnostic error is an ongoing patient safety challenge that can result in patient harm. This literature review identified a set of emergency department (ED)-focused electronic health record (EHR) triggers (e.g., death following ED visit, change in treating service after admission, unscheduled return to the ED resulting in admission) and non-EHR based signals (e.g., patient complaints, referral to risk management) with the potential to screen ED visits for diagnostic safety events.
Shenvi EC, Feupe SF, Yang H, et al. Diagnosis (Berl). 2018;5:235-242.
Seeking feedback on patient outcomes after a patient handoff takes place may provide useful learning for the provider who initially cared for the patient and inform future clinical decision-making. In this mixed-methods study, residents identified both a lack of time and inadequate systems for tracking patients as significant barriers to learning from the outcomes of patients they had handed over to other teams.
Shenvi EC, El-Kareh R. Diagnosis (Berl). 2015;2:3-19.
This review determined several candidate trigger criteria for retrospectively identifying diagnostic errors in hospitalized patients. These included triggers that are already in use for detecting adverse events (such as cardiopulmonary arrest or unplanned transfer to a higher level of care) and novel triggers (including change in code status and need for multiple subspecialty consults).
El-Kareh R, Gandhi TK, Poon EG, et al. J Gen Intern Med. 2009;24:464-8.
Less than 20% of ambulatory practices in the United States utilize electronic health records (EHRs). Uptake has been limited by cost issues and concern about the impact of EHRs on clinician workflow. This survey evaluated clinicians' perceptions of a newly implemented electronic medical record in three primary care clinics. Although initially clinicians felt that the EHR resulted in longer patient visits and increased the time spent documenting, by 1 year after implementation, clinicians felt that the EHR improved their ability to follow up on test results and communicate with other providers, and contributed to higher quality care overall. Importantly, these perceived advantages emerged only after 1 full year of using the new system.