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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 56 Results

Rosen M, Dy SM, Stewart CM, et al. Making Healthcare Safer IV Series.  Rockville, MD: Agency for Healthcare Research and Quality; July 2023. AHRQ Publication no. 23-EHC019-1.

… reliability , post-event communication programs ). … Rosen M, Dy SM, Stewart CM, et al. Making Healthcare Safer IV Series.  … … Sharma … Zhang … Vass … Motala … Bass … Michael … Sydney … Matthew … Paul … Amy … Jonathan … Ritu … Allen … …
Pitts S, Yang Y, Thomas BA, et al. J Am Med Inform Assoc. 2022;29:2101-2104.
The CancelRx tool is designed to improve communication between electronic health record (EHR) systems and pharmacy dispensing software. However, interoperability issues can limit the tool’s usefulness and result in inadvertent dispensing of discontinued medications. This evaluation of discontinued medications at one health systems over a one-month period found that only one-third to one-half of discontinued medications were e-prescribed using the same EHR system and would result in a CancelRx message to the pharmacy; the remainder of discontinued medications were patient-reported or reconciled from outside sources.
Xiao Y, Smith A, Abebe E, et al. J Patient Saf. 2022;18:e1174-e1180.
J Patient Saf … Older adults are particularly vulnerable to … medications and gaps in access to care. … Xiao Y, Smith A, Abebe E, et al. Understanding hazards for adverse drug … discharge: insights from frontline care professionals. J Patient Saf. Epub 2022 May 22. …
Watterson TL, Stone JA, Gilson A, et al. BMC Med Inform Decis Mak. 2022;22:50.
… BMC Med Inform Decis Mak … The CancelRx system is a health information technology-based intervention intended … data from the electronic health record (EHR) system of a midwestern academic health system, researchers found that implementing the CancelRx system resulted in a significant increase in successful medication …
Nassery N, Horberg MA, Rubenstein KB, et al. Diagnosis (Berl). 2021;8:469-478.
… in sepsis diagnosis. Using claims data, researchers used a ‘look back’ analysis to identify treat-and-release … hospitalization among adult emergency department patients: a look-back analysis employing insurance claims data using …
Horberg MA, Nassery N, Rubenstein KB, et al. Diagnosis (Berl). 2021;8:479-488.
… sepsis can lead to serious patient harm. This study used a Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) … mental status (AMS). FED and AMS were associated with a spike in sepsis hospitalizations in the 7-day period … after misdiagnosis in adult emergency department patients: a look-forward analysis with administrative claims data using …
Sharp AL, Baecker A, Nassery N, et al. Diagnosis (Berl). 2021;8:177-186.
… at Emergency Department (ED) visits within 30 days of a hospitalization for acute myocardial infarction (AMI) to … linked to probable missed diagnoses. Within 30 days of a subsequent hospitalization for AMI, common ED discharge … harms annually in the United States.   … Sharp AL, Baecker A, Nassery N, et al. Missed acute myocardial infarction in …
Chang BH, Hsu Y-J, Rosen MA, et al. Am J Med Qual. 2020;35:37-45.
… journal of the American College of Medical Quality … Am J Med Qual … Preventing health care–associated infections remains a patient safety priority. This multisite study compared … pneumonia before and after implementation of a multifaceted intervention. Investigators adopted the …
Lee JL, Dy SM, Gurses AP, et al. J Patient Exp. 2018;5:83-87.
Patient perspectives can identify previously undetected adverse events. This commentary discusses the value of seeking patient insights as an approach to measure medication safety and how such evaluation could affect implementation of meditation safety initiatives. The authors suggest adapting system-oriented approaches to reflect patient-centered concerns.
Marsteller JA, Hsu Y-J, Chan KS, et al. BMJ Qual Saf. 2017;26:288-295.
The Team Checkup Tool stemmed from work done as part of the Keystone ICU project and is designed to identify barriers to the progress of quality improvement initiatives. In this study, investigators used focus groups and feedback sessions to assess the content of the tool. They conclude that the Team Checkup Tool measures meaningful aspects of team-based quality improvement work.
Lashoher A, Schneider EB, Juillard C, et al. World J Surg. 2017;41:954-962.
… World journal of surgery … World J Surg … Checklists are widely utilized in health care to … in mortality for the overall study population, they found a 50% reduction in mortality for patients with more severe … trauma injuries after implementation of the program. A prior PSNet perspective discussed components of an …
Marsteller JA, Wen M, Hsu Y-J, et al. Ann Thorac Surg. 2015;100:2182-9.
This study found that cardiac surgical teams had a more positive safety culture (as measured by the AHRQ Hospital Survey on Patient Safety Culture) than other surgical teams. Similar to prior studies in which managers reported a more positive safety culture than frontline staff, in this study surgeons reported more optimal safety culture compared to nurses and perfusionists. This gap in perceived safety culture requires further study.