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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 39 Results
Liu Y, Jun H, Becker A, et al. J Prev Alz Dis. 2023;Epub Oct 24.
Persons with dementia are at increased risk for adverse events compared to those without dementia, highlighting the importance of a timely diagnosis. In this study, researchers estimate approximately 20% of primary care patients aged 65 and older are expected to have a diagnosis of mild cognitive impairment or dementia; however, only 8% have received such a diagnosis. Missed diagnosis prevents patients from receiving appropriate care, including newly FDA-approved medications to slow cognitive decline.

Twenter P. Becker's Clinical Leadership. October 30, 2023.

Health care has long held commercial aviation as a beacon to guide patient safety improvement work. This article examines how well aviation safety  mechanisms map to medical care safety efforts such as checklists, just culture and operating room black boxes.
Centola D, Becker J, Zhang J, et al. Proc Natl Acad Sci U S A. 2023;120:e2108290120.
Collective intelligence posits that the judgment (in this case, diagnostic accuracy) of a group of individuals outperforms the judgment of a single individual. This study sought to determine if real-time information-sharing improved not only group diagnostic accuracy, but also diagnostic accuracy of the individuals within the group. Individual accuracy did improve, suggesting real-time information-sharing between physicians could improve diagnostic decision-making in practice, although additional research is required.
Vickers-Smith R, Justice AC, Becker WC, et al. Am J Psych. 2023;180:426-436.
Racial and ethnic biases can affect diagnosis and negatively impact patient safety. Based on a sample of over 700,000 veterans, this study found that Black and Hispanic individuals consumed similar amounts of alcohol to White individuals but were more likely to be diagnosed with alcohol use disorder (AUD).

Bean M, Carbajal E. Becker's Hospital Review. March 29, 2023.

The RaDonda Vaught conviction reverberated throughout health care and marked weaknesses in systems response to errors and the clinicians who make them. This news article examines how health care organizations renewed efforts to establish and nurture a culture of safety and error reporting in service of safe patient care and learning from mistakes.
Montero-Odasso MM, Kamkar N, Pieruccini-Faria F, et al. JAMA Netw Open. 2021;4:e2138911.
Fall prevention in healthcare settings is a patient safety priority. This systematic review found that most clinical practice guidelines provide consistent recommendations for fall prevention for older adults. Guidelines consistently recommend strategies such as risk stratification, medication review, and environment modification.

Bean M, Masson G. Becker's Hospital Review. October 4, 2021.

Staffing shortages can impact the safety of care by enabling burnout, care omission, and staff attrition. This article discusses how the COVID-19 pandemic has necessitated an examination of how staffing challenges affect areas such as diagnosis, infection control, and organizational patient safety focus.
Becker C, Zumbrunn S, Beck K, et al. JAMA Netw Open. 2021;4:e2119346.
Discharge from the hospital represents a vulnerable time for patients. This systematic review assessed the impact of discharge communication on hospital readmissions, adherence to treatment regimen, patient satisfaction, mortality, and emergency department visits 30 days after hospital discharge. Findings suggest that improved communication at discharge reduced 30-day hospital readmissions and increased adherence to treatment regimen.
Jeffery MM, Chaisson CE, Hane C, et al. JAMA Netw Open. 2020;3.
Based on insurance claims data, this study measured the prevalence of opioid tolerance in patients initiating opioid regimens that require prior tolerance for safe use (such as transmucosal immediate-release fentanyl products). Less than half (48%) of episodes of treatment with an “opioid tolerant only” product occurred among patients with prior evidence of opioid tolerance in the claims data. Less than 1% of these episodes identified from prescription drug claims had evidence of opioid tolerance in structured electronic health records data but not claims data. Patients without opioid tolerance who are prescribed medications that are intended only for opioid-tolerant patients may be at increased risk of harms, including fatal overdose.
Becker RE. J Patient Saf. 2020;16.
This commentary explores two scientific cultures in modern medicine. A ‘traditional culture’ leaves error control up to individuals and groups of healthcare practitioners; the author describes how this culture leads to an overconfidence among practitioners about personal abilities to reduce errors. In contrast, a ‘modern scientific culture’ considers errors as inevitable and pervasive throughout medicine and beyond individuals or groups to control. The author describes the competing priorities of these cultures, and suggests that error control efforts in medicine will be more successful if there is a paradigm shift towards a more ‘modern’ attitude.

Dhaliwal G, Olson APJ, Singhal G, eds. Diagnosis (Berl). 2019;6(2):75-185.

Clinical and educational environments are increasingly focusing on improving diagnosis. This special issue explores an overarching approach to designing medical education strategies to address known weaknesses that affect diagnostic safety. Articles in the issue discuss the use of technology, diagnosis education, diagnostic processes in clinical contexts, and multidisciplinary improvement strategies.
Frank JW, Lovejoy TI, Becker WC, et al. Ann Intern Med. 2017;167:181-191.
Opioid medication use is associated with an increased risk of adverse drug events, including overdose-related deaths. A previous study demonstrated that patients prescribed higher doses of opioid medications or longer duration of opioid therapy were more likely to continue to use opioid medications over time. Although recent opioid prescribing guidelines recommend reducing doses and limiting duration of therapy, the impact of adherence to these guidelines on patient outcomes remains unknown. This systematic review included 67 studies involving dose reduction or discontinuation of long-term opioid therapy in patients being treated for chronic pain. Researchers conclude that the evidence on the effectiveness of interventions aimed at decreasing long-term opioid therapy and reducing doses on improving patient outcomes such as pain, function, and quality of life is limited. An accompanying editorial comments on the challenges associated with chronic pain management and acknowledges the need for further research in this area.

Jt Comm J Qual Patient Saf. 2017;43:315-337.

… the accomplishments of the 2016 recipients of the John M. Eisenberg Patient Safety and Quality Awards , this issue … Saf. 2017;43:315-337. … I-PASS Study Group; Campbell M: Mahoney D … CM … L. … AJ … ND … DC … TC … CP … S. … AK … J. … P. … T. … T. … R. … Clancy … Becker … Starmer … Spector … West … Sectish … Landrigan … …
Bae J, Rask KJ, Becker ER. Am J Med Qual. 2018;33:72-80.
Electronic health records enhance patient safety, but they also have unintended consequences. This retrospective study found that hospitals with a single-source electronic health record were less likely to have hospital-acquired safety events compared to hospitals with multiple systems in place. These results suggest that safety gaps may arise at the interface of multiple electronic systems.
Wright AP, Becker WC, Schiff G. JAMA Intern Med. 2016;176:7-8.
Opioid misuse is at epidemic proportions in the United States. This commentary advocates for physicians who recognize that their patients are misusing opioids to carefully approach changes in treatment strategies. Providers should adjust their prescribing behavior, counseling skills, and use of electronic health records to determine an effective care plan to address the patient's pain.
Frasier LL, Quamme SRP, Becker A, et al. JAMA Surg. 2017;152:109-111.
Teamwork training can improve communication and prevention of adverse events in the operating room. In this study, focus groups with clinicians and operating room staff found that team members perceived the concept of the "team" and their roles in ensuring optimal handoff communication differently. This exploratory work has implications for the design of effective teamwork training programs.
Körner M, Bütof S, Müller C, et al. J Interprof Care. 2016;30:15-28.
This systematic review found that features of interventions to enhance teamwork vary widely. Though many interventions are successful in improving teamwork and safety culture, it is unclear how these interventions work and therefore difficult to promote a specific strategy to enhance patient safety through teams.
DeHenau C, Becker MW, Bello NM, et al. Appl Ergon. 2016;52:77-84.
This study found that tall man lettering—in which specific letters in drug names are printed in capital letters to avoid being mistaken for a look-alike or sound-alike medication—led to more effective detection of changes between drugs by health care professionals and consumers. A prior WebM&M commentary discussed tall man lettering as one strategy for improving the safety of look-alike and sound-alike medications.