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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 96 Results
Gandhi TK, Schulson LB, Thomas AD. Jt Comm J Qual Patient Saf. 2023;Epub Sept 12.
Safety event reporting from both providers and patients is subject to bias. The authors of this commentary present several ways bias is introduced into reporting and offers strategies to ensure events are reported and analyzed in an equitable manner.

Jt Comm J Qual Patient Saf. 2023;49(9):435-450.

The legacy of AHRQ leader John Eisenberg, MD, still inspires safety improvement work decades after his passing. This special issue highlights the efforts of the 2022 Eisenberg Award honorees and their impact on improving patient safety and quality. The 2022 award recipients coved here include Jason S. Adelman, MD, MS, and North American Partners in Anesthesia (NAPA).
Gandhi TK. Jt Comm J Qual Patient Saf. 2023;49:235-236.
Safety event reporting is a primary method of gathering data to enhance learning from error. This commentary suggests that a broader approach is needed by engaging patients and gathering their perception of safety to provide a full picture of gaps in care that could result in harm.
Grauer A, Rosen A, Applebaum JR, et al. J Am Med Inform Assoc. 2023;30:838-845.
Medication errors can happen at any step along the medication pathway, from ordering to administration. This study focuses on ordering errors reported to the AHRQ Network of Patient Safety Databases (NPSD) from 2010 to 2020. The most common categories of ordering errors were incorrect dose, incorrect medication, and incorrect duration; nearly 80% of errors were definitely or likely preventable.
Rosen A, Carter D, Applebaum JR, et al. J Patient Saf. 2022;18:e1219-e1225.
The COVID-19 pandemic had wide-ranging impacts on care delivery and patient safety. This study examined the relationship between critical care clinician experiences related to patient safety during the pandemic and COVID-19 caseloads during the pandemic. Findings suggest that as COVID-19 caseloads increased, clinicians were more likely to perceive care as less safe.
Grauer A, Kneifati-Hayek J, Reuland B, et al. J Am Med Inform Assoc. 2022;29:909-917.
Problem lists, while an important part of high-quality care, are frequently incomplete or lack accuracy. This study examined the effectiveness of leveraging indication alerts in electronic health records (EHR) (medication ordered lacking a corresponding problem on the problem list) in two different hospitals using different EHRs. Both sites resulted in a proportion of new problems being added to the problem list for the medications triggered. Between 9.6% and 11.1% were abandoned (order started but not signed), which needs further study.
Kern-Goldberger AR, Kneifati-Hayek J, Fernandes Y, et al. Obstet Gynecol. 2021;138:229-235.
Patient misidentification errors can result in serious patient harm. The authors reviewed over 1.3 million electronic orders for inpatients at one New York hospital between 2016 and 2018 and found that wrong-patient order errors occurred more frequently on obstetric units than medical-surgical units. Medication errors were the largest source of order errors and commonly involved antibiotics and opioid and non-opioid analgesics.
Salmasian H, Blanchfield BB, Joyce K, et al. JAMA Netw Open. 2020;3:e2019652.
Patient misidentification can lead to serious patient safety risks. In this large academic medical center, displaying patient photographs in the electronic health record (EHR) resulted in fewer wrong-patient order entry errors. The authors suggest this may be a simple and cost-effective strategy for reducing wrong-patient errors.  
Singh H, Sittig DF, Gandhi TK. BMJ Qual Saf. 2021;30:141-145.
This Viewpoint presents examples of short-term positive effects resulting from early COVID-19-related patient safety efforts, including a focus on (1) high-reliability organizations and safety culture focusing on transparency, collaboration, reporting, and speaking up, (2) prioritizing workplace safety, and (3) removing barriers to using health IT (e.g., EHRs, telemedicine) to improve safety and how to create some permanent/sustainable methods to prevent harm.
Dadlez NM, Adelman JS, Bundy DG, et al. Ped Qual Saf. 2020;5:e299-e305.
Diagnostic errors, including missed diagnoses of adolescent depression, elevated blood pressure, and delayed response to abnormal lab results, are common in pediatric primary care. Building upon previous work, this study used root cause analyses to identify the failure points and contributing factors to these errors. Omitted process steps included failure to screen for adolescent depression, failure to recognize and act on abnormal blood pressure values, and failure to notify families of abnormal lab results. Factors contributing most commonly to these errors were patient volume, inadequate staffing, clinic environment, electronic and written communication, and provider knowledge.
Gandhi TK, Singh H. J. Hosp Med. 2020;15:363-366.
The authors present a nomenclature to describe eight types of diagnostic errors anticipated in the COVID-19 pandemic (classic, anomalous, anchor, secondary, acute collateral, chronic collateral, strain and unintended diagnostic errors) and highlight mitigation strategies to reduce potentially preventable harm, including the use of electronic decision support, communication tactics such as visual aids, and huddles. Organizational strategies (e.g., peer-support, duty hour limits, and forums for transparent communication) and state/federal guidance around testing and monitoring diagnostic performance are also discussed.
Franklin BJ, Gandhi TK, Bates DW, et al. BMJ Qual Saf. 2020;29:844–853.
Huddles are one technique to enhance team communication, identify safety concerns and built a culture of safety. This systematic review synthesized 24 studies examining the impact of either unit-based or hospital-wide/multiunit safety huddles. The majority of studies were uncontrolled pre-post study designs; only two studies were controlled and quantitatively measured intervention adoption and fidelity. Results for unit-based huddle programs appear positive. Given the limited number of studies evaluating hospital-wide huddle programs, the authors conclude that there is insufficient evidence to assess the benefit. Further research employing strong methodological designs is required to definitively assess the impact of huddle programs.
Gandhi TK, Feeley D, Schummers D. NEJM Catalyst. 2020;1.
… , and (4) patient engagement and codesign of healthcare. … Gandhi TK, Feeley D, Schummers D. Zero harm in health care …
Christiansen TL, Lipsitz S, Scanlan M, et al. Jt Comm J Qual Patient Saf. 2020.
The Fall TIPS (Tailoring Interventions for Patient Safety) program has been shown to be effective in preventing inpatient falls through formal risk assessment and tailored patient care plans. This study demonstrated that patients with access to the Fall TIPS program are more engaged and feel more confident in their ability to prevent falls than those who were not exposed to the program.
Adelman JS, Applebaum JR, Southern WN, et al. JAMA Pediatr. 2019;173:979-985.
A classic study found that the replacing the usual naming convention for newborns ("Babygirl" or "Babyboy") with one incorporating the mother's first name (e.g., "Marysgirl" or "Marysboy") reduced wrong-patient errors. Based on this finding, The Joint Commission issued a National Patient Safety Goal (NPSG) requiring the use of distinct naming systems for newborns. The authors of this study noted that the new standard would still leave multiple-birth infants vulnerable to wrong-patient errors, as most hospitals adopted naming standards that left room for confusion between infants (e.g., twin infants might be named "Marysgirl1" and "Marysgirl2"). Researchers examined the rate of wrong-patient errors in six neonatal intensive care units of two health systems that used the NPSG recommended naming conventions, comparing multiple-birth infants to singleton infants. They measured wrong-patient errors by tracking the rate of orders that were retracted and then immediately reordered for a different patient. The rate of wrong-patient errors was significantly higher among multiple-birth infants, most of which could be explained by intrafamilial errors (e.g., a medication was ordered for one twin when intended for another). The accompanying editorial points out that this study is an important example of carefully assessing the real-world impact of novel policies; in this case, the NPSG likely does protect against wrong-patient errors for singleton infants, but not for multiple-birth infants.