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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 81 Results
Lambert BL, Schiff GD. J Am Coll Clin Pharm. 2022;5:981-987.
In the wake of the criminal conviction of a nurse involved in a medical error, numerous organizations and institutions have warned of the negative impact it could have on learning and error disclosure. This commentary presents strategies to reduce the risk of criminal prosecution for pharmacists, including education of prosecutors and expert witnesses and minimization of overrides and workarounds.
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 … School of Medicine Baltimore, MD References 1. Zipperer L. COVID‑19: Team and human factors to improve safety. PSNet …

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.
Grauer A, Kneifati-Hayek J, Reuland B, et al. J Am Med Inform Assoc. 2022;29:909-917.
… health records (EHR) (medication ordered lacking a corresponding problem on the problem list) in two different … hospitals using different EHRs. Both sites resulted in a proportion of new problems being added to the problem list … but not signed), which needs further study. … Grauer A, Kneifati-Hayek J, Reuland B, et al. Indication alerts to …
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
… … The Commentary … By Stephen A. Martin, MD, EdM, Gordon D. Schiff, MD, Sanjat Kanjilal, MD, MPH False positive test … doi:10.1016/s1553-7250(10)36037-5. Jarrom D, Elston L, Washington J, et al. Effectiveness of tests to detect the …
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.

Perspective on Safety February 21, 2020
… care.     Contributing authors have nothing to disclose. … Gordon Schiff, MD … Associate Director, Center for Patient Safety … 10.1177/0300060518782519. [ PubMed ] [5] Llor C, Bjerrum L. Antimicrobial resistance: risk associated with antibiotic …
This perspective describes key themes reflected in AHRQ PSNet resources released in 2019 related to patient safety in primary care.
Lambert BL, Galanter W, Liu KL, et al. BMJ Qual Saf. 2019;28:908-915.
… BMJ Qual Saf … Look-alike and sound-alike (LASA) drugs are a well-established source of medication errors that place … data on medication orders and diagnostic claims data from a single academic medical center as well as data on … to improve specificity and sensitivity of this approach. A past WebM&M commentary discussed a case involving the …
Olson A, Rencic J, Cosby K, et al. Diagnosis (Berl). 2019;6:335-341.
… Diagnosis (Berl) … Mitigating diagnostic error has become a critical patient safety concern . As a result, medical education and training programs are … safety. This article describes the development of a novel interprofessional framework to improve diagnostic …
Aaronson E, Quinn GR, Wong CI, et al. J Healthc Risk Manag. 2019;39:19-29.
… and causes of cancer misdiagnoses. Similar to a prior study , investigators found that missed cancer … 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. …
Bergl PA, Wijesekera TP, Nassery N, et al. Diagnosis (Berl). 2020;7:3-9.
The Improving Diagnosis in Health Care report launched the universal effort to address diagnostic error and seek strategies for improvement. Analyzing the diagnostic error literature published between 2016 and 2018, this review identifies themes associated with diagnostic error definitions, clinical reasoning teaching methods, and use of artificial intelligence and presents the pros and cons of each topic.