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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 - 18 of 18 Results
Trowbridge RL, Reilly JB, Clauser JC, et al. Diagnosis (Berl). 2018;5:229-233.
This simulation study presented virtual patient cases to practicing physicians with the aim of improving diagnostic accuracy. Physician participants reported challenges using the computerized platform, and overall diagnostic performance was poor, with less than a third of respondents identifying the correct diagnosis. This study highlights the challenge of developing interventions to enhance diagnostic performance.
Sellers MM, Berger I, Myers JS, et al. J Surg Educ. 2018;75:e168-e177.
This qualitative study examined incident reports about surgical patients, comparing trainee reports to those submitted by attending surgeons and nurses. Trainees were more likely to enter reports anonymously and completed more elements for each report, but they also used more blame language and submitted fewer reports overall. The results suggest that encouraging trainee reporting may shed light on surgical safety.
Ban KA, Chung JW, Matulewicz RS, et al. J Am Coll Surg. 2016;224.
Analyzing data from a prior trial of flexible versus traditional duty hours, this study found that female residents perceived patient safety as worse than male residents. Changes in duty hours had mixed effects on these self-reported outcomes and seemed to exacerbate gender differences. The authors recommend further study to determine how to improve learning for trainees regardless of gender.
WebM&M Case March 1, 2017
A woman taking modified-release lithium for bipolar disorder was admitted with cough, slurred speech, confusion, and disorientation. Diagnosed with delirium attributed to hypercalcemia, she was treated with aggressive hydration. She remained disoriented and eventually became comatose. After transfer to the ICU, she was diagnosed with nephrogenic diabetes insipidus due to lithium toxicity.
Bates KE, Shea JA, Bird GL, et al. Jt Comm J Qual Patient Saf. 2016;42:562-AP4.
Hospitals rely on incident reporting systems to detect safety issues, but these systems are voluntary and do not capture all adverse events or near misses. Researchers developed and tested a prospective surveillance tool to identify teamwork errors in the pediatric intensive care unit. They found that this tool helped uncover safety issues not captured by the hospital's patient safety reporting system.
Reilly JB, Myers JS, Salvador D, et al. Diagnosis (Berl). 2014;1:167-171.
This commentary discusses how two medical centers utilized the fishbone diagram as a tool to analyze diagnostic errors. A health care facility in Maine developed a root cause analysis model to determine common factors, and a residency program in Pennsylvania introduced a modified fishbone diagram to educate trainees about cognitive biases and systems issues.
Buser GL, Fisher BT, Shea JA, et al. Am J Infect Control. 2013;41:492-6.
Engaging patients has been an area of emphasis for the safety movement, spurred by data demonstrating that patients often feel uncomfortable asking questions of their clinicians. This survey found that most parents of hospitalized children were interested in participating in hand hygiene efforts, but one-third would feel uncomfortable reminding health care workers to wash their hands. This reluctance has been documented in prior studies and may arise from patients' fear of endangering their relationship with the care team. In order to address these barriers, the Agency for Healthcare Research and Quality recently published a guide to patient and family engagement in quality and safety programs, which was designed with input from clinicians and patients.
Ogdie AR, Reilly JB, Pang WG, et al. Acad Med. 2012;87:1361-7.
Diagnostic errors have been described as the next frontier in patient safety. Cognitive biases are common causes for these errors but have remained an elusive target for medical educators. This study describes an educational intervention for internal medicine residents consisting of reflective writing and facilitated small group discussions about personal experiences with diagnostic errors. Participating residents identified at least one cognitive bias and one contextual factor that may have contributed to their error. The most frequently implicated biases were anchoring and availability. Most residents also described a strategy to prevent similar errors in the future. A near miss stemming from an initial diagnostic error is highlighted in an AHRQ WebM&M commentary.
Shea JA, Willett LL, Borman KR, et al. Acad Med. 2012;87:895-903.
Conducted before implementation of the 2011 ACGME duty hour limits, this survey found that the majority of internal medicine and surgery program directors believed the new regulations would negatively affect the learning environment and continuity of care, as well as result in increased faculty workload and require changes in clinical services.