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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 20 Results
Mehta SD, Congdon M, Phillips CA, et al. J Hosp Med. 2023;18:509-518.
Improving diagnosis in pediatrics is an ongoing patient safety focus. This retrospective study included 129 pediatric emergency transfer cases and examined the relationship between missed opportunity for improvement in diagnosis (MOID; determined using SaferDx) and patient outcomes. Researchers found that MOID occurred in 29% of emergency transfer cases and it was associated with higher risk of mortality and longer post-transfer length of stay.
Congdon M, Rauch B, Carroll B, et al. Hosp Pediatr. 2023;13:563-571.
Diagnostic errors in pediatrics remain a significant focus of patient safety. This study uses two years of unplanned readmissions to a children’s hospital to identify missed opportunities for improving diagnosis (MOID). Clinician decision-making and diagnostic reasoning were identified as key factors for MOID. The authors recommend that future research include larger cohorts to identify populations and conditions at increased risk for MOID-related readmissions.
Mahajan P, Grubenhoff JA, Cranford J, et al. BMJ Open Qual. 2023;12:e002062.
Missed diagnostic opportunities often involve multiple process breakdowns and can lead to serious avoidable patient harm. Based on a web-based survey of 1,594 emergency medicine physicians, missed diagnostic opportunities most frequently occur in children who present to the emergency department with undifferentiated symptoms (e.g., abdominal pain, fever, vomiting) and often involve issues related to the patient/parent-provider interaction, such as misinterpreting patient history or inadequate physical exam.
Joseph MM, Mahajan P, Snow SK, et al. Pediatrics. 2022;150:e2022059673.
Children with emergent care needs are often cared for in complex situations that can diminish safety. This joint policy statement updates preceding recommendations to enhance the safety of care to children presenting at the emergency department. It expands on the application of topics within a high-reliability framework focusing on leadership, managerial factors, and organizational factors that support safety culture and workforce empowerment to support safe emergency care for children.
Ren DM, Abrams A, Banigan M, et al. Simul Healthc. 2022;17:e45-e50.
Effective team communication is a cornerstone to ensuring safe patient care, particularly during stressful situations. To evaluate baseline team communication behavior, clinicians at this institution participated in interprofessional video-recorded simulations of a code response and debriefing, followed by standardized evaluations by external reviewers. Evaluations indicate variable performance on different team communication behaviors (highest for escalating care and thinking out loud, lowest for verbally establishing leadership). The authors suggest that assessing baseline communication behaviors can guide future interventions to promote and improve quality and patient safety.
Mahajan P, Pai C-W, Cosby KS, et al. Diagnosis (Berl). 2021;8:340-346.
Diagnostic error is an ongoing patient safety challenge that can result in patient harm. This literature review identified a set of emergency department (ED)-focused electronic health record (EHR) triggers (e.g., death following ED visit, change in treating service after admission, unscheduled return to the ED resulting in admission) and non-EHR based signals (e.g., patient complaints, referral to risk management) with the potential to screen ED visits for diagnostic safety events.
Goyal MK, Johnson TJ, Chamberlain JM, et al. Pediatrics. 2020;145:e20193370.
Systemic racism is associated with suboptimal treatment of acute and chronic pain. In pediatric emergency department patients with long-bone fractures, minority children were more likely to receive analgesics and achieve at least a 2-point reduction in pain, but they were less likely to receive opioids and achieve optimal pain reduction.
Mahajan P, Basu T, Pai C-W, et al. JAMA Netw Open. 2020;3:e200612.
Using data from a large commercial insurance claims database, this cohort study sought to identify factors associated with potentially missed appendicitis by comparing patients with a potentially missed diagnosis versus patients diagnosed with appendicitis on the same day in the emergency department. The researchers estimated the frequency of missed appendicitis was 6% among adults and 4.4% among children. Patients presenting with abdominal pain and constipation were more likely to have a missed diagnosis of appendicitis than patients presenting with isolated abdominal pain or abdominal pain with nausea and/or vomiting. Stratified analyses based on undifferentiated symptoms found that women and patients with comorbidities were more likely to have missed appendicitis.
Myers JS, Lane-Fall MB, Perfetti AR, et al. BMJ Qual Saf. 2020;29:645-654.
… BMJ Qual Saf … BMJ Qual Saf … This study used a mixed-methods approach to characterize the impact of two … institutions. Students in these programs reported a positive impact of the fellowship on their careers, with nearly all being involved in QIPS administration, research or education upon graduation. Interviewed mentors …
Ku BC, Chamberlain JM, Shaw KN. Pediatr Clin North Am. 2018;65:1269-1281.
Pediatric emergency care presents unique safety challenges for a vulnerable patient population. This review summarizes emergency department (ED) improvement work across the six domains of quality. The authors suggest that pediatric EDs adopt high reliability concepts to enhance collaboration and data-sharing to improve safety. They also call for increased focus on equity and patient-centeredness.
Medford-Davis LN, Singh H, Mahajan P. Pediatr Clin North Am. 2018;65:1097-1105.
The busy and complex emergency department environment harbors pressures can that hinder diagnostic safety. This review discusses the characteristics of emergency medicine that contribute to overreliance on heuristics and susceptibility to bias in decision making. The authors highlight the need to better monitor diagnostic error in the emergency department to inform the design of improvement activities. A previous WebM&M commentary discussed diagnostic delay in the emergency department.
OʼConnell KJ, Shaw KN, Ruddy RM, et al. Pediatr Emerg Care. 2018;34:237-242.
Deviating from standard work processes has the potential to compromise safety. Using data from the Pediatric Emergency Care Applied Research Network, researchers analyzed incident reports determined to be process variance events. They found that 5.6% of events resulted in some form of temporary patient harm.
Benjamin L, Frush K, Shaw KN, et al. Ann Emerg Med. 2018;71:e17-e24.
Emergency departments harbor conditions that can hinder safe medication administration for pediatric patients. This policy statement identifies and prioritizes improvements such as implementing kilogram-only weight-based dosing, involving pharmacists in frontline emergency care, and utilizing computerized provider order entry and clinical decision support systems.
Blumberg SM, Mahajan P, OʼConnell KJ, et al. Pediatr Emerg Care. 2017;33:92-96.
This study analyzed a database of voluntarily reported errors to determine the types of radiologic errors encountered in a regional pediatric emergency medicine network. Radiologic errors accounted for 7% of all incident reports, of which the most common were incorrect or changed interpretations of studies. Individual errors—including clinical judgment or failure to follow established safety procedures—were judged to be more common than system factors, though only half of the incident reports described contributing causes.
Ruddy RM, Chamberlain JM, Mahajan P, et al. BMJ Open. 2015;5:e007541.
This study of incident reports from pediatric emergency departments found that a small proportion reported near misses or unsafe conditions. Common issues included medication safety, handoffs, human factors, and systems vulnerabilities, all of which are known to lead to patient harm. Prior studies have found that incident reporting is often underused. This study highlights its importance as a lens into safety problems.
Goyal MK, Kuppermann N, Cleary SD, et al. JAMA Pediatr. 2015;169:996-1002.
… identified racial differences in pain management among pediatric patients with appendicitis. Compared to white … receive opioids for severe pain. … Goyal  MK, Kuppermann N, Cleary SD, et al. Racial disparities in pain management of children with appendicitis in emergency departments. JAMA Pediatr. 2015;169(11):996-1002. …
Taylor AM, Chuo J, Figueroa-Altmann A, et al. Jt Comm J Qual Patient Saf. 2013;39:396-403.
Leadership WalkRounds—derived from the business management approach of "management by walking around"—are being more widely used as a means of error detection and improving safety culture. This report from a children's hospital, in which structured walkrounds by nursing and physician leaders were implemented on six units, found that this approach increased staff engagement in safety efforts, identified hidden system flaws, and resulted in the successful implementation of multiple quality improvement projects. Although this study did not specifically measure the effect of walkrounds on safety climate, prior studies have found conflicting results, which might imply that different methods of performing walkrounds may influence their success.