Skip to main content

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.

Search All Content

Search Tips
Selection
Format
Download
Filter By Author(s)
Advanced Filtering Mode
Date Ranges
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Additional Filters
Approach to Improving Safety
Clinical Area
Safety Target
Selection
Format
Download
Displaying 1 - 20 of 918 Results
Ledger TS, Brooke-Cowden K, Coiera E. J Am Med Inform Assoc. 2023;30:2064-2071.
Computerized provider order entry (CPOE) systems can reduce medication errors by alerting prescribers to a variety of potential adverse events. However, too many alerts may result in alert fatigue. This scoping review identified 16 studies on interventions to reduce alert fatigue. Most interventions focused on drug-drug interactions. A decrease in the quantity and frequency of alerts was seen as a positive outcome, however only four of the studies reported any patient safety outcomes.
Sittig DF, Yackel EE, Singh H. J Gen Intern Med. 2023;38:940-942.
Large-scale technology modifications can contribute to organizational disfunction. This commentary discusses five approaches to managing disruption associated with electronic health record modernization that establish cultural, functionality, staff, design, and monitoring conditions to reduce stress and the potential for patient harm during technology improvements.
Hibbert PD, Stewart S, Wiles LK, et al. Int J Qual Health Care. 2023;Epub Oct 17.
Quality improvement and patient safety initiatives require incredible human and financial resources, they so must be selected carefully to achieve the greatest return on investment. This article describes important considerations for hospital leaders when selecting and implementing initiatives. Safety culture, policies and procedures, supporting staff, and patient engagement were notable themes. The included "patient safety governance model" provides a framework to develop patient safety policy.
Metz VE, Ray GT, Palzes V, et al. J Gen Intern Med. 2023;Epub Nov 6.
In response to the increasing opioid crisis, many medical associations, policy makers, and insurers have argued for dose reductions. However, when doses are reduced too quickly, patients may experience short- and long-term adverse events. Consistent with other studies, dose reductions higher than 30% were associated with higher odds of emergency department visits, opioid overdose, and all-cause mortality in the month following dose reduction.
Ravindran S, Matharoo M, Rutter MD, et al. Endoscopy. 2023;Epub Sept 18.
Understanding the influence of human factors on team and system performance can help safety professionals identify opportunities for improvement. In this study, researchers used a large, centralized incident reporting database in the United Kingdom to examine the human factors contributing to non-procedural endoscopy-related patient safety incidents. Based on Human Factors Analysis and Classification System coding, decision-based errors were the most common factor contributing to incidents, but other contributing factors were also identified, including lack of resources and ineffective team communication.
Cam H, Wennlöf B, Gillespie U, et al. BMC Health Serv Res. 2023;23:1211.
When patients are discharged from the hospital, they (and their informal caregivers) are given copious amounts of information that must also be communicated to their primary care provider. This qualitative study of primary care and hospital physicians, nurses, and pharmacists highlights several barriers to complete and effective communication between levels of care, particularly regarding geriatric medication safety. Barriers include the large number of complex patients and incongruent expectations of responsibility of primary and hospital providers. Support systems, such as electronic health records, can both enable and hinder communication.
Olazo K, Gallagher TH, Sarkar U. J Patient Saf. 2023;19:547-552.
Marginalized patients are more likely to experience adverse events and it is important to encourage effective disclosure to reinforce and reestablish trust between patients and providers. This qualitative study involving clinicians and patient safety professionals explored challenges responding to and disclosing errors involving historically marginalized patients. Participants identified multilevel challenges, including fragmentation of care and patient mistrust as well a desire for disclosure training and culturally appropriate disclosure toolkits to support effective error disclosure.
Pozzobon LD, Rotter T, Sears K. Healthc Manage Forum. 2023;Epub Oct 13.
Patient and caregiver engagement in patient safety can improve individual outcomes and help identify safety threats. This article highlights the advantages of including patients in patient safety event reporting, including broadening the understanding of harm to include psychological and financial harms, identifying contributing factors to harm, and notes several organizational activities where patients and caregiver involvement can be integrated.
Ali KJ, Goeschel CA, DeLia DM, et al. Diagnosis (Berl). 2023;Epub Oct 5.
To improve patient safety, payers such as the Centers for Medicare & Medicaid have implemented policies that limit reimbursement for certain healthcare-associated harms. This commentary introduces the “Payer Relationships for Improving Diagnoses (PRIDx)” framework describing how payers may implement similar policies to reduce diagnostic errors.
Gandhi TK, Schulson LB, Thomas AD. Jt Comm J Qual Patient Saf. 2023;Epub Sept 12.
Safety event reporting from both providers and patients is subject to bias. The authors of this commentary present several ways bias is introduced into reporting and offers strategies to ensure events are reported and analyzed in an equitable manner.
Huth K, Hotz A, Emara N, et al. J Patient Saf. 2023;19:493-500.
The transition from hospital to home is a vulnerable time as patients may have changes in medications or care needs, or difficulties accessing follow up with an outpatient provider. To reduce adverse events (AE), rehospitalizations, and emergency department visits, this hospital developed a structured discharge bundle based on the I-PASS tool used for inpatient handoffs. AE, rehospitalizations, and emergency department visits were all reduced following implementation of the I-PASS bundle.
Meidert U, Dönnges G, Bucher T, et al. Int J Environ Res Public Health. 2023;20:6569.
Biases among healthcare professionals can lead to inequitable care and poor patient outcomes. Based on 81 included studies, the authors of this scoping review concluded that racial bias among physicians and nurses in the United States is well-documented, but noted that research on biases among other health professionals or in other countries is lacking.
Georgiou A, Li J, Thomas J, et al. Public Health Res Pract. 2023;33:e3332324.
Several systemic factors may hinder communication of test results to patients and clinicians. This article describes a research project in Australia, "Delivering safe and effective test result communication, management and follow-up." Along with previously identified test result communication challenges such as workflow and technology, this paper highlights the need for national thresholds for critical laboratory results.

Peterson M. Los Angeles Times. September 5, 2023.

Safe practice in community pharmacy is challenged by production pressure, workforce shortages, and multitasking. This story examined the mistakes made at major retail pharmacy chains in California. It provides examples perpetrated across the industry to target universal areas of needed improvement and potential strategies to address them.
Rapp T, Sicsic J, Tavassoli N, et al. Eur J Health Econ. 2023;24:1085-1100.
Potentially inappropriate prescribing in long-term care facilities increases the risk of adverse drug events and other adverse outcomes, including increased healthcare costs. Based on a secondary data analysis from the Systematic Dementia Screening by Multidisciplinary Team Meetings in Nursing Homes for Reducing Emergency Department Transfers (IDEM) randomized trial, this study found that increases in potentially inappropriate prescribing increased residents’ risk of going to the emergency room and increased total medication spending.
Bell SK, Harcourt K, Dong J, et al. BMJ Qual Saf. 2023;Epub Aug 21.
Patient and family engagement is essential to effective and safe diagnosis. OurDX is a previsit online engagement tool to help identify opportunities to improve diagnostic safety in patients and families living with chronic conditions. In this study, researchers implemented OurDX in specialty and primary care clinics at two academic healthcare organizations and examined the potential safety issues and whether patient/family contributions were integrated into the post-visit notes. Qualitative analysis of 450 OurDX reports found that participants contributed important information about the diagnostic process. Participants with diagnostic concerns were more likely to raise concerns about the diagnostic process (e.g., access barriers, problems with tests/referrals, communication breakdowns), which may represent diagnostic blind spots.
Hose B-Z, Carayon P, Hoonakker PLT, et al. Appl Ergon. 2023;113:104105.
Health information technology (IT) usability continues to be a source of patient harm. This study describes the perspectives of a variety of pediatric trauma team members (e.g., pediatric emergency medicine attending, surgical technician, pediatric intensive care unit attending) on the usability of a potential team health IT care transition tool. Numerous barriers and facilitators were identified and varied across department and role.

Bradford A, Goeschel C, Shofer M, et al. Am Fam Physician. 2023;108(1):14-16.

Diagnostic errors are common in the ambulatory environment. This article discusses five tools to help primary care practices implement diagnostic safety improvement strategies. The authors share overarching considerations to support tool implementation including keeping efforts modest and seeing diagnostic safety beyond the clinical realm.

James C, Singh K, Valley TS, et al. Rockville, MD; Agency for Healthcare Research and Quality; July 2023. AHRQ Publication No. 23-0040-4-EF.

As artificial intelligence (AI) and machine learning (ML) become established in health care, it is critical for clinicians and patients to effectively collaborate to use AI safely. This Issue Brief adds to a series of diagnostic-focused reports and presents a framework to guide patients and clinicians on working as team members when using AI and ML to make diagnostic decisions.