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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 - 7 of 7 Results
Auerbach AD, Astik GJ, O’Leary KJ, et al. J Gen Intern Med. 2023;38:1902-1910.
COVID-19 ushered in new diagnostic challenges and changes in care practices. In this study conducted during the first wave of the pandemic, charts for hospitalized adult patients under investigation (PUI) for COVID-19 were reviewed for potential diagnostic error. Diagnostic errors were identified in 14% of cases; patients with and without diagnostic errors were statistically similar and errors were not associated with pandemic-related change practices.
Auerbach AD, O'Leary KJ, Greysen SR, et al. J Hosp Med. 2020;15:483-488.
Based on a survey of hospital medicine groups at academic medical centers in the United States (conducted April 2020), the authors of this study characterized inpatient adaptations to care for non-ICU COVID-19 patients. Sites reported rapid expansion of respiratory isolation units (RIUs – dedicated units for patients with known or suspected COVID-19), an emphasis on telemedicine for patient evaluation, and implementation of approaches to minimize room entry. In addition, nearly half of responding sites reported diagnostic errors involving COVID-19 (missing non-COVID-19 diagnoses among infected patients and missing COVID-19 diagnoses in patients admitted for other reasons).
Moy NY, Lee SJ, Chan T, et al. Jt Comm J Qual Patient Saf. 2014;40:219-227.
This quality improvement evaluation found that a structured inpatient-to-outpatient handoff tool in the electronic health record was successfully implemented and improved the timeliness of communication, a key step in preventing postdischarge adverse events.
Sarkar U, Lopez A, Maselli JH, et al. Health Serv Res. 2011;46:1517-1533.
This study represents the first attempt to estimate the nationwide incidence of adverse drug events (ADEs) in ambulatory care. The investigators estimate that nearly 4.5 million ambulatory visits occur yearly due to ADEs, with older patients and patients who take more than 6 medications daily being at increased risk. The study did not assess preventability of ADEs, but prior studies have found that many patients suffer preventable ADEs in the outpatient setting; these were often linked to known high-risk medications. An AHRQ WebM&M commentary discusses an outpatient ADE related to a pharmacy dispensing error, and the Patient Safety in Ambulatory Care Primer discusses ADEs and other common outpatient safety issues.
Auerbach AD, Sehgal NL, Blegen MA, et al. BMJ Qual Saf. 2011;21.
Focused efforts to enhance teamwork and communication have led to improved safety culture, though the impact on clinical outcomes is mixed. This multicenter study evaluated the impact of a series of teamwork and communication interventions over a 2-year period. The interventions included a teamwork training program, the development of unit-based safety teams, and patient engagement through daily goals and whiteboard use. Although a related study demonstrated that the interventions led to improved safety culture, this study found no impact on readmission rates or length of stay. Interviewing patients both during and after hospitalization, investigators found that patients perceived greater team function, but that they also perceived more safety gaps. This raises the possibility that patients' heightened awareness regarding patient safety and teamwork may lead them to identify more flaws in the system.