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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 69 Results
Wong CI, Vannatta K, Gilleland Marchak J, et al. Cancer. 2023;129:1064-1074.
Children with complex home care needs, such as children with cancer, are particularly vulnerable to medication errors. This longitudinal study used in-home observations and chart review to monitor 131 pediatric patients with leukemia or lymphoma for six months and found that 10% experienced adverse drug events due to medication errors in the home and 42% experienced a medication error with the potential for harm. Failures in communication was the most common contributing factor. Findings underscored a critical need for interventions to support safe medication use at home. Researchers concluded that improvements addressing communication with and among caregivers should be co-developed with families and based on human-factors engineering.
WebM&M Case December 14, 2022
… and Treatment of Strongyloides stercoralis Infection. Ann Pharmacother . 2007;41(12):1992-2001. [ Available at ] … North Am . 2020;104(1):1-14. [ Free full text ] Singer R, Xu TH, Herrera LNS, et al. Prevalence of intestinal … (Review Article). [ Free full text ] Kane JC, Elafros MA, Murray SM, et al. A scoping review of health-related stigma …
Perspective on Safety August 5, 2022
… Perspective, we benefited from the input and insights of Gordon Schiff, MD, the Quality and Safety Director for the Harvard … any of which may lead to patient harm. Follow-up failures (i.e., incomplete or delayed communication of test results) …

The focus on patient safety in the ambulatory setting was impacted by the COVID-19 pandemic and appropriately shifting priorities to responding to the pandemic. This piece explores some of the core themes of patient safety in the ambulatory setting, including diagnostic safety and diagnostic errors. Ways to enhance patient safety in the ambulatory care setting and next steps in ambulatory care safety are addressed. 

Nehls N, Yap TS, Salant T, et al. BMJ Open Qual. 2021;10:e001603.
Incomplete or delayed referrals from primary care providers to specialty care can cause diagnostic delays and patient harm. A systems engineering analysis was conducted to identify vulnerabilities in the referral process and develop a framework to close the loop between primary and specialty care. Low reliability processes, such as workarounds, were identified and human factors approaches were recommended to improve successful referral rates.
WebM&M Case January 7, 2022

An 18-year-old man with a history of untreated depression and suicide attempts (but no history of psychiatric hospitalizations) was seen in the ED for suicidal ideation after recent gun purchase. Due to suicidal ideation, he was placed on safety hold and a psychiatric consultation was requested. The psychiatry team recommended discharge with outpatient therapy; he was discharged with outpatient resources, the crisis hotline phone number, and strict return precautions.

WebM&M Case August 25, 2021

A 31-year-old woman presented to the ED with worsening shortness of breath and was unexpectedly found to have a moderate-sized left pneumothorax, which was treated via a thoracostomy tube. After additional work-up and computed tomography (CT) imaging, she was told that she had some blebs and mild emphysema, but was discharged without any specific follow-up instructions except to see her primary care physician.

Galanter W, Eguale T, Gellad WF, et al. JAMA Netw Open. 2021;4:e2117038.
One element of conservative prescribing is minimizing the number of medications prescribed. This study compared the number of unique, newly prescribed medications (personal formularies) of primary care physicians across four health systems. Results indicated wide variability in the number of unique medications at the physician and institution levels. Further exploration of personal formularies and core drugs may illuminate opportunities for safer and more appropriate prescribing.
WebM&M Case April 28, 2021
… Healy B, Khan A, Metezai H, Blyth I, Asad H. The impact of false positive COVID-19 results in … Accessed February 1, 2021. Mina MJ, Parker R, Larremore DB. Rethinking Covid-19 Test Sensitivity — A … Reaction–Based SARS-CoV-2 Tests by Time Since Exposure. Ann Intern Med . 2020:M20-1495. doi:10.7326/M20-1495. …
WebM&M Case December 23, 2020

After a breast mass was identified by a physician assistant during a routine visit, a 60-year-old woman received a diagnostic mammogram and ultrasound. The radiology assessment was challenging due to dense breast tissue and ultimately interpreted as “probably benign” findings. When the patient returned for follow-up 5 months later, the mass had increased in size and she was referred for a biopsy.

Myers LC, Gartland RM, Skillings J, et al. Acad Med. 2020;95:1215-1222.
This case-control study using medical malpractice claims identified patient-, provider-, and claim-related factors in claims directly involving physician trainees in the events. The majority of claims were procedure-related and the most common diagnosis in claims cases was puncture or laceration during surgery. Inadequate supervision was a common contributing factor.
Sheridan S, Merryweather P, Rusz D, et al. Washington, DC: National Academy of Medicine; 2020.
Safety initiatives can be enhanced by engaging patients in the development process. This report highlights one project as an example of how to involve patients as partners in diagnostic improvement research projects. The program resulted in a curriculum that prepared patients to participate as team members in diagnostic improvement studies.
Perspective on Safety February 21, 2020
This perspective describes key themes reflected in AHRQ PSNet resources released in 2019 related to patient safety in primary care.
This perspective describes key themes reflected in AHRQ PSNet resources released in 2019 related to patient safety in primary care.
Rozenblum R, Rodriguez-Monguio R, Volk LA, et al. Jt Comm J Qual Patient Saf. 2019;46:3-10.
Clinical decision support (CDS) tools help identify and reduce medication errors but are limited by the rules and types of errors programmed into their alerting logic and their high alerting rates and false positives, which can contribute to alert fatigue. This retrospective study evaluates the clinical validity and value of using a machine learning system (MedAware) for CDS as compared to an existing CDS system. Chart-reviewed MedAware alerts were accurate (92%) and clinically valid (79.7%). Overall, 68.2% of MedAware alerts would not have been generated by the CDS tool and estimated cost savings associated with the adverse events potentially prevented via MedAware alerts were substantial ($60/drug alert).
Aaronson E, Jansson P, Wittbold K, et al. Am J Emerg Med. 2020;38:1584-1587.
This study evaluated the efficacy of reviewing ED return visits that result in an ICU admission to determine if they were associated with deviations in care and to understand the common errors. They found that of patients who were return ED visits and admitted to the ICU, 44% (223 cases) returned for reasons associated with the index visit and, in those, 14% (31 cases) had a deviation in care at the index visit. Implementing a standard diagnostic process of care framework to those 31 cases with a deviation in care, 47.3% had a failure in the initial diagnostic pathway. The authors concluded reviewing 14 day returns with ICU admissions contribute to better understanding of diagnostic and systems errors.
WebM&M Case October 30, 2019
… has been a positive safety intervention, we now know that (i) it has not fulfilled its promise of preventing many types … http://www.ncbi.nlm.nih.gov/pubmed/16117752 Koppel R. What do we know about medication errors made via a CPOE … http://www.ncbi.nlm.nih.gov/pubmed/17327525 Ai A, Wong A, Amato M, Wright A. Communication failure: analysis of …
Lambert BL, Galanter W, Liu KL, et al. BMJ Qual Saf. 2019;28:908-915.
Look-alike and sound-alike (LASA) drugs are a well-established source of medication errors that place patients at risk for adverse drug events. Prior research has shown that these medications can be automatically identified using diagnostic codes at the time of electronic prescribing. Using electronic health record data on medication orders and diagnostic claims data from a single academic medical center as well as data on medication indications, researchers developed an algorithm to identify LASA prescribing errors. Although the algorithm was able to identify LASA prescribing errors that may not have been found by other means, the positive predictive value was 12.1% and the false-positive rate was greater than 75%. The authors advocate for further research to improve specificity and sensitivity of this approach. A past WebM&M commentary discussed a case involving the mix-up of two medications with similar names.
Brunsberg KA, Landrigan CP, Garcia BM, et al. Acad Med. 2019;94:1150-1156.
Physician burnout and depression are prevalent, costly, and likely to worsen the existing physician shortage. Physicians with depression and burnout also report committing more errors than their peers. Investigators prospectively examined whether pediatric residents reporting depression or burnout were involved in more errors. Participants experiencing depression committed three times as many harmful errors as those without depression. Residents with burnout did not commit more errors or more harmful errors. A strength of this study is that the errors were assessed objectively rather than by self-report. The direction of causality remains unclear—whether physicians with depression commit more harm or committing harm leads to depression. A past PSNet interview discussed how to promote physician satisfaction and well-being.
Aaronson E, Quinn GR, Wong CI, et al. J Healthc Risk Manag. 2019;39:19-29.
Malpractice risk in the outpatient setting is significant and claims often involve missed and delayed diagnoses. This retrospective study examined diagnostic error claims in outpatient general medicine to identify characteristics and causes of cancer misdiagnoses. Similar to a prior study, investigators found that missed cancer diagnosis is the leading type of diagnostic error in primary care, constituting nearly half of closed diagnostic claims. Contributing factors included failure or delay in test ordering or consultation. These findings suggest that improving test results management and consultative processes may reduce malpractice risk related to outpatient diagnosis. A previous WebM&M commentary discussed an incident involving a missed diagnosis of spinal cord injury in primary care.