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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 40 Results
Prieto JM, Falcone B, Greenberg P, et al. J Surg Res. 2022;279:84-88.
Hospitalized children are vulnerable to patient safety risks. Using a large malpractice claims database, researchers found that a wide range of pediatric surgical specialties – including orthopedics, general surgery, and otolaryngology – are most frequently associated with malpractice lawsuits. The study identified several potentially modifiable factors (i.e., patient evaluations, technical performance, and communication) that can lead to improvements in pediatric surgical safety.
Logan MS, Myers LC, Salmasian H, et al. J Patient Saf. 2021;17:e1726-e1731.
This article describes an innovative expert consensus process to generate a contemporary list of chart-review based triggers and adverse event measures for assessing the incidence of inpatient and outpatient adverse events. A panel of 71 experts from nine institutions identified 218 triggers and measures with high or very high clinical importance deemed suitable for chart review and 198 were found suitable for electronic surveillance; 192 items were suitable for both.   
Gleason KT, Jones RM, Rhodes C, et al. J Patient Saf. 2021;17:e959-e963.
This study analyzed malpractice claims to characterize nursing involvement in diagnosis-related (n=139) and failure-to-monitor malpractice (n=647) claims. The most common contributing factors included inadequate communication among providers (55%), failure to respond (41%), and documentation failures (28%). Both diagnosis-related and physiologic monitoring cases listing communication failures among providers as a contributing factor were associated with a higher risk of death (odds ratio [OR]=3.01 and 2.21, respectively). Healthcare organizations need to take actions to enhance nurses’ knowledge and skills to be better engage them in the diagnostic process, such as competency training and assessment.
Liberman AL, Skillings J, Greenberg P, et al. Diagnosis (Berl). 2020;7:37-43.
Ischemic stroke, which often presents with non-specific symptoms and requires time-sensitive treatment, can be a source of diagnostic error and misdiagnosis. Using a large medical malpractice claims database, this study found that nearly half of all malpractice claims involving ischemic stroke included diagnostic errors, primarily originating in the ED. The analysis found that breakdowns in the initial patient-provider encounter (e.g., history and physical examination, symptom assessment, and ordering of diagnostic tests) contributed to most malpractice claims.
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.
Abrecht CR, Brovman EY, Greenberg P, et al. Anesth Analg. 2017;125:1761-1768.
Opioid prescriptions for chronic, noncancer pain have contributed to the national opioid epidemic. Malpractice claims can identify trends in patient hazards and have been previously employed to better elucidate the opioid risks. This retrospective observational study examined all closed claims from a large malpractice carrier levied against pain medicine physicians. The resulting sample included 37 cases. Researchers found that improper medication management was the most common reason for a claim and only 27% resulted in payment. No claim filed when a provider terminated opioid therapy resulted in payment. Most of the patients who died in this study had cardiac, pulmonary, or psychiatric comorbidities. The authors recommend adhering to opioid prescribing guidelines, communicating opioid prescribing risks to patients, documenting those conversations, and monitoring for diversion as strategies to reduce malpractice claims. An Annual Perspective summarized opioid-related patient safety research.
Quinn GR, Ranum D, Song E, et al. Jt Comm J Qual Patient Saf. 2017;43:508-516.
This analysis of closed malpractice claims sought to characterize the types of errors leading to malpractice claims in patients with cardiovascular disease. Diagnostic errors, especially in patients presenting with nonspecific symptoms but risk factors for cardiovascular disease, were a common cause of claims, implying that improving the accuracy of diagnosing cardiovascular disease may be a promising avenue for reducing morbidity.
Starmer AJ, Schnock KO, Lyons A, et al. BMJ Qual Saf. 2017;26:949-957.
Handoffs increase the risk of adverse events, mainly due to lapses in communication. Implementation of a standardized approach to handoffs may help improve patient safety. This prospective pre–post intervention study examined the impact of a multicomponent handoff intervention consisting of education, verbal handoff mnemonic implementation (I-PASS), and visual aids on nursing handoffs. Researchers used assessment tools to evaluate both the quality and duration of handoffs. Implementation of the intervention was associated with an overall improvement in the handoff process and did not adversely impact nursing workflow. A previous Annual Perspective highlighted safety issues related to handoffs and care transitions.
Schiff G, Nieva HR, Griswold P, et al. Med Care. 2017;55:797-805.
A recent AHRQ technical brief on ambulatory safety found that evidence for effective interventions is lacking. This cluster-randomized controlled trial examined whether participation in a multimodal quality improvement intervention enhanced safety processes at primary care clinics compared to usual practice. Using chart review, investigators determined that clinics receiving the intervention—which included a learning network, webinars, in-person meetings, and coaching—improved documentation and patient notification for abnormal test results overall. Also, time between test date and treatment plan was shorter in intervention sites. Through pre–post surveys, they learned that patient perceptions of quality and safety improved modestly for coordination and communication but were otherwise similar between the sites. Staff perceptions of safety and quality were similar pre–post and between intervention and control sites. Barriers to improvement included time and resource constraints, staff turnover, health information technology, and local practice variation. The authors recommend further study to determine the potential for multimodal practice-level interventions to enhance outpatient safety.
Graber ML, Siegal D, Riah H, et al. J Patient Saf. 2019;15:77-85.
Although heath information technology (IT) has improved patient safety, studies have shown that implementing electronic health records can introduce new errors. This study examined closed malpractice claims related to health IT. Most cases occurred in ambulatory care settings, suggesting that current health IT may not be optimally designed to support safety in those settings. Cases involving medication errors, diagnostic errors, or treatment complications were almost equally prevalent, indicating that health IT vulnerabilities span multiple tasks and functions. Software design issues and implementation problems also played a role in these incidents. These findings emphasize the need to reexamine health information technologies and how they are implemented in health care systems to enhance safety. A recent PSNet perspective examined challenges in health IT implementation, and another perspective discussed the need for innovations in health IT usability.
Starmer AJ, Spector ND, Srivastava R, et al. New Engl J Med. 2014;371:1803-1812.
The number of handoffs a patient experiences while hospitalized has almost certainly increased at academic institutions after the implementation of duty hour restrictions, posing a significant threat to patient safety. In response, The Joint Commission required that all hospitals maintain a standardized approach to handoff communication, and in 2010 the Accreditation Council for Graduate Medical Education required that all residents receive formal handoff training. This multicenter study demonstrates that implementation of a standardized handoff bundle—which included a mnemonic ("I-PASS") for standardized oral and written signouts, formal training in handoff communication, faculty development, and efforts to ensure sustainability—was associated with a 23% relative reduction in the incidence of preventable adverse events across 9 participating pediatric residency programs. This improvement was achieved through a very high level of resident engagement in the revised handoff process, but did not negatively affect resident workflow. This rigorously designed and analyzed study establishes the I-PASS model as the gold standard for effective clinical handoffs and demonstrates the value of methodologically stringent approaches to addressing patient safety issues. A case of a delayed diagnosis due to poor handoffs is discussed in a past AHRQ WebM&M commentary.
Nanji KC, Rothschild JM, Boehne JJ, et al. J Am Med Inform Assoc. 2014;21:481-6.
Computerized provider order entry (CPOE) systems have been widely implemented to prevent adverse drug events due to prescribing errors. This direct observation and interview study in an outpatient pharmacy setting describes changes in practice as a result of electronic prescribing. Consistent with prior studies investigating unintended consequences of CPOE, researchers identified new errors associated with electronic prescribing, as well as potential methods to reduce adverse drug events. To improve safety, the authors recommend developing systems to track abandoned prescriptions, offering incentives for pharmacies to utilize electronic prescribing, and enhancing the interface between electronic health record and pharmacy computer systems to decrease manual entry, limit duplicated prescriptions, and expedite clarification requests. A past AHRQ WebM&M commentary describes how a nurse entered an outpatient prescription for the wrong patient and deleted it, mistakenly assuming it would cancel the order.
Starmer AJ, Sectish TC, Simon DW, et al. JAMA. 2013;310:2262-2270.
Handoff improvement is a national patient safety priority. The Accreditation Council for Graduate Medical Education now requires residency programs to provide formal handoff education to trainees. This study evaluated the implementation of an inpatient handoff bundle for pediatric resident physicians. The multifaceted intervention included team training, standardized communication, electronic documentation, and new team handoff structures. In the uncontrolled, before-and-after analyses, medical errors and preventable adverse events decreased substantially. The intervention did not adversely affect resident workflow. Residents were found to spend more time in direct contact with patients in the post-intervention period. A related editorial notes that this study presents promising evidence that improving handoffs can reduce patient harm.
Schiff G, Puopolo AL, Huben-Kearney A, et al. JAMA Intern Med. 2013;173:2063-8.
Malpractice risk in outpatient primary care is increasingly under scrutiny. This study screened malpractice claims from two Massachusetts insurers and found that those from outpatient primary care settings were more likely to be settled or found in favor of the plaintiff compared with those from other practice settings. Similar to previous research, claims related to missed and delayed diagnoses were most frequent, and the most common disease involved was cancer, followed by cardiovascular disease. The accompanying editorial argues that primary care settings will become increasingly important for malpractice claims with the advent of patient-centered medical homes and accountable care organizations, which shift a larger proportion of medical care to the outpatient primary care setting. The authors note a high prevalence of failure-to-diagnose claims and recommend further emphasis on diagnostic safety. A missed diagnosis of myocardial infarction was discussed in an AHRQ WebM&M commentary.
Zimlichman E, Henderson D, Tamir O, et al. JAMA Intern Med. 2013;173:2039-2046.
Health care–associated infections (HAIs) remain a major contributor to preventable morbidity and mortality in hospitalized patients, despite some progress in combating certain infections. This economic analysis combined a systematic review of estimates of costs attributable to HAIs with HAI incidence data to project hospitals' total financial burden caused by these infections in adult inpatients. The authors conclude that the 5 most common HAIs result in an annual cost to the health care system of nearly $10 billion. Since the majority of HAIs are considered preventable, this finding implies that considerable savings could be achieved through more rigorous HAI prevention efforts. Although the study is limited by the heterogeneous methods of determining costs used in the original studies, other studies have shown a relatively strong business case for hospitals to invest in efforts to prevent HAIs.
Zimlichman E, Keohane C, Franz C, et al. Jt Comm J Qual Patient Saf. 2013;39:312-318.
The uptake of computerized provider order entry (CPOE) in community hospitals has been slow due to difficulties associated with implementation and uncertainty about its real-world performance. One recent study demonstrated that commercial CPOE systems can effectively prevent adverse drug events (ADEs) in community hospitals. This follow-up study sought to establish the business case for CPOE through calculating the hospitals' return on investment (ROI)—accounting for the costs saved by preventing ADEs in relation to the cost of buying and implementing the system. Perhaps the study's greatest utility is that it provides data on the actual implementation costs of CPOE in the community setting, but the ROI for hospitals was modest at best and was actually negative at some hospitals. The authors note that the CPOE system in question had minimal decision support capabilities and even a small increase in ADE prevention via decision support would have improved the ROI. Findings from this study demonstrate that economic evaluation of safety strategies is urgently needed.
Leung AA, Keohane C, Lipsitz S, et al. J Am Med Info Asso. 2013;20:e85-e90.
As more hospitals begin to implement computerized provider order entry (CPOE) systems, rigorously evaluating their real-world performance at preventing medication errors has become crucial. The Leapfrog Group was an early pioneer in calling for wider CPOE implementation, and this study reports on the validation of a tool developed by Leapfrog for assessing the ability of CPOE systems to prevent serious errors. The tool, which uses simulated cases, proved to be effective, as the incidence of errors it detected corresponded closely to the actual error rates of participating hospitals. Prior simulation research has shown that many commercial systems fail to detect even potentially serious errors, and this study provides reassurance that CPOE systems that pass the Leapfrog evaluation are likely to successfully prevent medication errors.
Kale A, Keohane C, Maviglia SM, et al. BMJ Qual Saf. 2012;21:933-8.
Efforts to improve medication safety focus on preventing potential adverse drug events (ADEs, medication errors with a high likelihood of resulting in patient harm), under the assumption that preventing these near misses will reduce medication-related harm. However, the proportion of potential ADEs that result in actual preventable ADEs is controversial. This analysis of data from a prior study of medication administration errors found that 7.5% of potential ADEs resulted in actual clinical harm for patients. The authors point out that this apparently low incidence of preventable ADEs would still result in more than 4000 preventable ADEs every year at a 700-bed hospital.