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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 - 14 of 14 Results
Barnett ML, Meara E, Lewinson T, et al. New Engl J Med. 2023;388:1779-1789.
Best practices for treating patients with opioid use disorder (OUD) include prescribing medications to treat OUD (naltrexone, naloxone, or buprenorphine) and limiting prescriptions of high-risk medications (opioid analgesics and benzodiazepines). This study of more than 23,000 patients with an index event related to OUD sought to determine racial and ethnic differences in safe prescribing. White patients were significantly more likely to receive buprenorphine and less likely to receive high-risk medications than Black or Hispanic patients in the 180 days after the index event. This difference persisted over the four-year study period.
Keller SC, Caballero TM, Tamma PD, et al. JAMA Netw Open. 2022;5:e2220512.
Prescribing antibiotics increases the risk of resistant infections and can lead to patient harm. From December 2019 to November 2020, 389 ambulatory practices participated in a quality improvement project using the Agency for Healthcare Research and Quality Safety Program for Improving Antibiotic Use Program. The goal of the intervention was to support implementation and sustainment of antibiotic stewardship into practice culture, communication, and decision-making. Practices that completed the program and submitted data showed a significant decrease of antibiotic prescribing for acute respiratory infections at program completion in November 2020.
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.
Chua K-P, Fischer MA, Linder JA. BMJ. 2019;364:k5092.
Prescribing unnecessary antibiotics increases the risk of resistant infections and can lead to patient harm. In this cross-sectional study, researchers found that 23% of the 15,455,834 outpatient antibiotic prescriptions filled among a cohort of 19.2 million patients over a 1-year period were consistent with inappropriate prescribing.
Vaughn VM, Linder JA. BMJ Qual Saf. 2018;27:583-586.
Despite the benefits of health information technology, such systems can have detrimental effects on clinician decision-making. This commentary discusses how electronic health record design can contribute to inappropriate test ordering. The author recommends that influences such as heuristics and social norms be considered when developing electronic health record systems to improve care.
Semigran HL, Levine DM, Nundy S, et al. JAMA Intern Med. 2016;176:1860-1861.
… … Information technology approaches have been advocated as a means of preventing diagnostic error. This study compared … consistently arrived at more accurate diagnoses across a variety of simulated cases. …
Schoenfeld AJ, Davies JM, Marafino BJ, et al. JAMA Intern Med. 2016;176:635-42.
There seems to be an increasing patient demand for immediately accessible virtual medical visits via the Internet. Although provision of this service has proliferated, little is known about the quality of care delivered by these models. This audit study used trained standardized patients—"secret shoppers"— to present common acute illnesses to the eight most popular commercial virtual visit websites. Physicians correctly named diagnoses in 77% of the visits, but key management decisions complied with guidelines in only about half of cases. The quality of care provided varied widely across websites. Virtual visit physicians frequently prescribed antibiotics inappropriately, though this is also true in traditional clinic settings. Conversely, physicians generally did not order additional testing, even when it would be recommended by guidelines, such as in ankle pain cases with specific concerning signs. These findings call for further study to understand these emerging models of care delivery and specific opportunities to improve quality and safety in these settings.
Linder JA, Doctor JN, Friedberg MW, et al. JAMA Intern Med. 2014;174:2029-31.
Unnecessary prescribing of antibiotics for viral conditions can pose patient safety risks. This study found that primary care physicians are more likely to prescribe antibiotics inappropriately toward the end of their clinic session (late morning or late afternoon), which likely represents clinicians' decision fatigue.
Linder JA, Ma J, Bates DW, et al. Arch Intern Med. 2007;167:1400-5.
This cross-sectional study found that outpatient practices' use of an electronic health record (EHR) was not associated with higher quality care. The authors posit several reasons for this finding, including the possibility that EHRs were not implemented as fully as at benchmark institutions, or lacked decision support.