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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 310 Results
Levine DM, Syrowatka A, Salmasian H, et al. Ann Intern Med. 2024;Epub May 7.
Although most care occurs in outpatient settings, research into adverse events (AE) in this setting remains sparse in comparison to acute care. In this study, the medical records of patients who received outpatient care (e.g., primary, radiology, emergency, ambulatory surgery) in Massachusetts in 2018, were reviewed for any occurrence of adverse events. Seven percent had at least one AE, most commonly adverse drug events, and 23% were potentially preventable. Most AE originated from care in the physician's office.

Ratwani RM, Bates DW, Gold J. Health Affairs Forefront. April 25, 2024.

Design and user issues are persistent detractors from the reliability of electronic health records (EHRs) in the diagnostic process. This piece explores the lack of knowledge regarding the intersection of EHRs and diagnostic error. It suggests enhanced EHR design and training as avenues toward improvement.
Rodriguez JA, Samal L, Ganesan S, et al. J Patient Saf. 2024;20:247-251.
The COVID-19 pandemic led to dramatic changes in healthcare delivery and presented new challenges to safe patient care. Among patients ages 18 years and older admitted to the hospital between January 2019 and June 2020, this study found that the first surge of the COVID-19 pandemic was not associated with an increase in patient safety events (measured using the AHRQ patient safety indicators) among patients without COVID-19. Among the individual PSIs, only in-hospital falls with hip fractures were significantly higher during the first surge of the pandemic.
Ratwani RM, Bates DW, Classen DC. JAMA Health Forum. 2024;5:e235514.
Artificial intelligence (AI) is being widely discussed as a tool that will prevent failures in decision making that lead to patient harm. This commentary submits three approaches to ensuring AI is developed and installed in a safe and reliable manner that complements United States government AI quality efforts: guideline development and adherence, system patient safety threat monitoring, and process development for tracking AI as a contributor to patient safety events.
Sarkar U, Bates DW. JAMA Intern Med. 2024;184:343-344.
Artificial intelligence (AI) has the potential to improve care delivery in a variety of healthcare settings. This article describes how AI tools can be leveraged in primary care and provides several examples, such as supporting clinician documentation, between-visit management and communication, and individualized decision support.  
Co Z, Classen DC, Cole JM, et al. Appl Clin Inform. 2023;14:981-991.
Computerized provider order entry (CPOE) alert prescribers to potentially unsafe medication orders, such as drug-drug interactions or dosing errors. In this study, ten outpatient clinics used the Ambulatory Electronic Health Record (EHR) Evaluation Tool to evaluate the ability of their CPOE to detect medication safety errors. Scores varied widely between clinics and between order entry categories (e.g., a low of 3% for drug monitoring and high of 100% for drug-allergy).
Carvalho REFL de, Bates DW, Syrowatka A, et al. BMJ Open Qual. 2023;12:e002310.
Research has shown a robust safety culture improves patient outcomes, reduces length of hospital stay, and increases patient and staff satisfaction. As such, safety culture is increasingly being measured by healthcare organizations. This review sought to identify the factors measured by safety culture instruments in hospitals. The Hospital Survey on Patient Safety Culture and Safety Attitudes Questionnaire were the most frequently used instruments. Important factors include organizational, professional, and patient and family participation, although none of the instruments measured all three.
Classen DC, Longhurst CA, Davis T, et al. JAMA Netw Open. 2023;6:e2333152.
Electronic health records (EHR) with computerized provider order entry (CPOE) help prevent many types of medication errors but poor user design can hinder these benefits. Using scores from the National Quality Forum Leapfrog Health IT Safety Measure and the ARCH Collaborative EHR User experience survey, this study compares safety scores and physician perceptions of usability. Results indicate a positive association between safety performance and user experience, affirming the importance of user-centered design.
Schnipper JL, Reyes Nieva H, Yoon CS, et al. BMJ Qual Saf. 2023;32:457-469.
Implementing successful interventions to support effective medication reconciliation is an ongoing challenge. The MARQUIS2 study examined whether system- and patient-level interventions plus physician mentors can improve medication reconciliation and reduce medication discrepancies. This analysis based on patient exposure in the MARQUIS2 study found that patient receipt of a best possible medication history (BPMH) in the emergency department and medication reconciliation at admission and discharge were associated with the largest reductions in medication discrepancy rates.
Emani S, Rodriguez JA, Bates DW. J Am Med Inform Assoc. 2023;30:995-999.
Electronic health records (EHR) are essential for recording patients' clinical data but may also perpetuate stigma, particularly for people of color. This article describes how the EHR can perpetuate individual, organizational, and structural racism and ways organizations, researchers, practitioners, and vendors can address racism.
Bates DW, Williams EA. J Allergy Clin Immunol Pract. 2022;10:3141-3144.
Electronic health records (EHRs) are key for the collection of patient care data to inform overarching risk management and improvement strategies. This article discusses the adoption of EHRs as tools supporting patient safety and highlights the need for an expanded technology infrastructure to continue making progress.
Schnock KO, Garber A, Fraser H, et al. Jt Comm J Qual Patient Saf. 2023;49:89-97.
Reducing diagnostic errors is a primary patient safety concern. This qualitative study based on interviews with 17 providers and two focus group with seven patient advisors found broad agreement that diagnostic errors pose a significant threat to patient safety, as participants had difficulty defining and describing, and correctly identifying. the frequency of diagnostic errors in acute care settings. Participants cited issues such as communication failures, diagnostic uncertainty, and cognitive load as the primary factors contributing to diagnostic errors.
Dykes PC, Curtin-Bowen M, Lipsitz S, et al. JAMA Health Forum. 2023;4:e225125.
Patient falls are associated with poorer clinical outcomes, and increased costs to the health system. This study describes the economic costs of implementing the Fall Tailoring Interventions for Patient Safety (Fall TIPS) Program in eight American hospitals. Results show the Fall TIPS program reduced falls by 19%, avoiding over $14,000 of costs per 1,000 patient days.
Bates DW, Levine DM, Salmasian H, et al. New Engl J Med. 2023;388:142-153.
An accurate understanding of the frequency, severity, and preventability of adverse events is required to effectively improve patient safety. This study included review of more than 2,800 inpatient records from 11 American hospitals with nearly one quarter having at least one preventable or not preventable adverse event. Overall, approximately 7% of all admissions included at least one preventable event and 1% had a severity level of serious or higher. An accompanying editorial by Dr. Donald Berwick sees the results of this study as a needed stimulus for leadership to prioritize patient safety anew.
Sheikh A, Coleman JJ, Chuter A, et al. Programme Grants Appl Res. 2022;10:1-196.
Electronic prescribing (e-prescribing) is an established medication error reduction mechanism. This review analyzed experiences in the United Kingdom to understand strengths and weaknesses in e-prescribing. The work concluded that e-prescribing did improve safety in the UK and that the implementation and use of the system was a complex endeavor. The effort produced an accompanying toolkit to assist organizations in e-prescribing system decision making.
Carlile N, Fuller TE, Benneyan JC, et al. J Patient Saf. 2022;18:e1142-e1149.
The opioid epidemic has prompted national and institutional guidelines for safe opioid prescribing. This paper describes the development, implementation, and sustainment of a toolkit for safer opioid prescribing for chronic pain in primary care. The authors describe organizational, technical, and external barriers to implementation along with attempted solutions and their effects. The toolkit is available as supplemental material.
Apathy NC, Howe JL, Krevat S, et al. JAMA Health Forum. 2022;3:e223872.
Electronic Health Record (EHR) systems are required to meet meaningful use and certification standards to receive incentive payments from the US Department of Health and Human Services (HHS). This study identified six settlements reached between EHR vendors and the Department of Justice for misconduct related to certification of meaningful use. Certification of EHR systems that don’t meet HHS meaningful use requirements may have implications for patient safety.
WebM&M Case December 14, 2022

This case describes a man in his 70s with a history of multiple myeloma and multiple healthcare encounters for diarrhea in the previous five years, which had always been attributed to viral or unknown causes, without any microbiologic or serologic testing. The patient was admitted to the hospital with gastrointestinal symptoms and diagnosed with cholecystitis and gangrenous gallbladder. Two months after his admission for cholecystitis, he was readmitted for severe vomiting and hypotension.

Malik MA, Motta-Calderon D, Piniella N, et al. Diagnosis (Berl). 2022;9:446-457.
Structured tools are increasingly used to identify diagnostic errors and related harms using electronic health record data. In this study, researchers compared the performance of two validated tools (Safer Dx and the DEER taxonomy) to identify diagnostic errors among patients with preventable or non-preventable deaths. Findings indicate that diagnostic errors and diagnostic process failures contributing to death were higher in preventable deaths (56%) but were also present in non-preventable deaths (17%).
Perspective on Safety August 5, 2022

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.