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
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Search By Author(s)
PSNet Original Content
Additional Filters
Displaying 1 - 19 of 19 Results
Kaufman RM, Dinh A, Cohn CS, et al. Transfusion (Paris). 2019;59:972-980.
Wrong-patient errors in blood transfusion can lead to serious patient harm. Research has shown that use of barcodes to ensure correct patient identification can reduce medication errors, but less is known about barcoding in transfusion management. This pre–post study examined the impact of barcode labeling on the rate of wrong blood in tube errors. Investigators found that use of barcoding improved the accuracy of labels on blood samples and samples that had even minor labeling errors had an increased chance of misidentifying the patient. The authors conclude that the results support the use of barcoding and the exclusion of blood samples with even minor labeling errors in order to ensure safe blood transfusion. An accompanying editorial delineates the complex workflow, hardware, and software required to implement barcoding for transfusion. A past WebM&M commentary discussed an incident involving a mislabeled blood specimen.
Siam B, Al-Kurd A, Simanovsky N, et al. JAMA Surg. 2017;152:679-685.
Balancing supervision and autonomy for trainee physicians is a contested area in patient safety. This analysis of medical record data at a single institution compared complication rates following acute appendectomy between surgical resident physicians and attending surgeons. As measured by a composite score, the complication rate did not differ between trainees and attending surgeons. There was no difference in the rate of follow-up imaging, length of stay, or duration of antibiotics following surgery. On average, trainees took about 9 minutes longer to complete the surgery. The authors conclude that trainees do not require attending supervision to safely perform appendectomies. A related editorial calls for greater surgical resident autonomy and notes the importance of real-life experience with procedures to prepare residents for independent practice. A past PSNet perspective explored this tension between supervision and autonomy in medical education.
Obermeyer Z, Cohn B, Wilson M, et al. BMJ. 2017;356:j239.
The emergency department is considered a high-risk setting for diagnostic errors. This analysis of Medicare claims data found that a significant number of adults age 65–89 died within a week of visiting and being discharged from an emergency department, even when no life-limiting illness was noted. Hospitals that admit a lower proportion of emergency department patients to the inpatient setting had a higher mortality rate among discharged patients, even after adjusting for patient characteristics. Consistent with prior studies relating patient outcomes to volume, higher-volume emergency departments had lower 7-day mortality among discharged patients. These results suggest that emergency department discharges may represent missed diagnoses. A WebM&M commentary discussed an incident involving a patient who died after being discharged from the emergency department.
Mello MM, Greenberg Y, Senecal SK, et al. Health Serv Res. 2016;51 Suppl 3:2583-2599.
Communication-and-resolution programs underscore the importance of early disclosure of medical error to patients and families. Prior research highlights implementation challenges associated with these efforts. Investigators analyzed 125 adverse event cases from 5 New York City hospitals over a 22-month period following the implementation of communication-and-resolution programs. The majority of cases did not involve substandard care, and disclosure occurred in more than 90% of cases.

Ridgely MS, Greenberg MD, Clancy CM, eds. Health Serv Res. 2016;51(suppl 3):2395-2648.

… KM … DK … YJ … DM … Y … PI … TH … SK … JS … MS … MD … MB … J … W … JW … KK … K … R … JH … M … S … LW … M … WM … MC … GD … P … N … J … M … SJ … Battles … Reback … Azam … Boothman … Burstein … … … Studdert … Greenberg … McCotter … Gallagher … Senecal … Cohn … Ridgely … Greenberg … Pillen … Bell … Riley … Begun … …
WebM&M Case June 1, 2016
… died shortly thereafter. … The Commentary … by Steven L. Cohn, MD … Communication failures are a major safety problem … on the effectiveness of medical consultations. Am J Med. 1983;74:106. [go to PubMed] 4. Horwitz RI, Henes CG, … and management efficacy of medical consultations. J Chronic Dis. 1983;36:213. [go to PubMed] 5. Pupa LE Jr, …
Mello MM, Senecal SK, Kuznetsov Y, et al. Health Aff (Millwood). 2014;33:30-8.
This study reports on an AHRQ-funded effort to establish communication-and-resolution protocols for general surgery in five New York City hospitals. The participating hospitals improved their incident disclosure but also encountered many critical obstacles to full implementation.
Sage WM, Gallagher TH, Armstrong S, et al. Health Aff (Millwood). 2014;33:11-9.
Communication-and-resolution programs continue to face challenges to implementation despite their demonstrated value. This commentary recommends policy adjustments for legal, payment, and peer review protection to address barriers to implementing such programs and optimize their widespread adoption.
Health Aff (Millwood). 2014;33:6-66.
… strategies. … JM … MJ … L … WM … SK … TH … EJ … A … CK … J … L … P … JK … A … A … M … LM … J … MM … SK … Y … JS … RC … T … J … A … D … B … T … DA … J … … Isavoran … Crider … Smith … Mello … Senecal … Kuznetsov … Cohn … Boothman … McDonald … Driver … Lembitz … Bouwmeester … …
Cohn J. The Atlantic. March 2013;311:59–67.
… efficiency and accuracy of health care decision making. … Cohn J. The Atlantic. March 2013;311:59–67. … JCohnJ Cohn
Stewart RM, Corneille MG, Johnston J, et al. Ann Surg. 2006;243:645-9; discussion 649-51.
This study demonstrated that discussion of cases at traditional morbidity and mortality (M&M) conferences did not lead to increased risk of litigation. Investigators at a single academic institution used a trauma registry (risk-management database) along with minutes from M&M conferences to evaluate the ratio of lawsuits filed to patients admitted, those admitted with complications, and those presented at M&M conferences. The authors discuss the clinical and legal information from selected malpractice suits but ultimately suggest that their findings support educational venues to discuss medical errors. Furthermore, they discuss the importance of such activities in the context of the patient safety movement and performance improvement activities. A past study evaluated M&M conferences in both surgery and internal medicine to determine the frequency with which cases involving medical errors are discussed.