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.
Doctor JN, Stewart E, Lev R, et al. JAMA Netw Open. 2023;6:e2249877.
… … Research has shown that prescribers who are notified of a patient’s fatal opioid overdose will decrease milligram … than the control group during the 4-12 month period. … Doctor JN, Stewart E, Lev R, et al. Effect of prescriber notifications of patient’s …
Prescribing antibiotics increases the risk of resistant infections and can lead to patient harm. From December 2019 to November 2020, 389 ambulatory practices participated in a quality improvement project using the Agency for Healthcare Research and Quality Safety Program for Improving Antibiotic Use Program. The goal of the intervention was to support implementation and sustainment of antibiotic stewardship into practice culture, communication, and decision-making. Practices that completed the program and submitted data showed a significant decrease of antibiotic prescribing for acute respiratory infections at program completion in November 2020.
One element of conservative prescribing is minimizing the number of medications prescribed. This study compared the number of unique, newly prescribed medications (personal formularies) of primary care physicians across four health systems. Results indicated wide variability in the number of unique medications at the physician and institution levels. Further exploration of personal formularies and core drugs may illuminate opportunities for safer and more appropriate prescribing.
Schnipper JL, Reyes Nieva H, Mallouk M, et al. BMJ Qual Saf. 2022;31:278-286.
… pragmatic quality improvement study (MARQUIS2) implemented a refined toolkit including system-level and patient-level … mediation discrepancies over time. … Schnipper JL, ReyesNieva H, Mallouk M, et al. Effects of a refined …
Doctor JN, Nguyen A, Lev R, et al. Science. 2018;361:588-590.
High-risk opioid prescribing by providers contributes to opioid misuse. Prior studies have shown that patients frequently receive opioid prescriptions even if they have a history of overdose. In this randomized trial involving 861 providers prescribing opioids to 170 patients who experienced fatal overdose, providers in the intervention arm were notified about patients' deaths by the county medical examiner while those in the control arm were not. Researchers found that milligram morphine equivalents prescribed to the patients of providers who received the death notifications decreased by almost 10% in the 3-month period following the intervention. There were no significant changes in the prescribing patterns of the control group. An Annual Perspective discussed patient safety and opioid medications.
Vaughn VM, Linder JA. BMJ Qual Saf. 2018;27:583-586.
Despite the benefits of health information technology, such systems can have detrimental effects on clinician decision-making. This commentary discusses how electronic health record design can contribute to inappropriate test ordering. The author recommends that influences such as heuristics and social norms be considered when developing electronic health record systems to improve care.
Schiff G, Nieva HR, Griswold P, et al. Med Care. 2017;55:797-805.
A recent AHRQ technical brief on ambulatory safety found that evidence for effective interventions is lacking. This cluster-randomized controlled trial examined whether participation in a multimodal quality improvement intervention enhanced safety processes at primary care clinics compared to usual practice. Using chart review, investigators determined that clinics receiving the intervention—which included a learning network, webinars, in-person meetings, and coaching—improved documentation and patient notification for abnormal test results overall. Also, time between test date and treatment plan was shorter in intervention sites. Through pre–post surveys, they learned that patient perceptions of quality and safety improved modestly for coordination and communication but were otherwise similar between the sites. Staff perceptions of safety and quality were similar pre–post and between intervention and control sites. Barriers to improvement included time and resource constraints, staff turnover, health information technology, and local practice variation. The authors recommend further study to determine the potential for multimodal practice-level interventions to enhance outpatient safety.
Schiff G, Nieva HR, Griswold P, et al. Health Serv Res. 2016;51 Suppl 3:2634-2641.
Prior research has shown that malpractice risk in the outpatient setting is significant and that claims frequently involve missed and delayed diagnoses. This editorial describes lessons learned from the Massachusetts PROMISES (Proactive Reduction of Outpatient Malpractice: Improving Safety, Efficiency, and Satisfaction) project. Funded by the Agency for Healthcare Research and Quality, the PROMISES project involved a multipronged intervention within 16 randomly selected primary care practices to address known areas of risk in ambulatory care, including test result management, referrals, medication management, and communication issues. A previous PSNet perspective discussed how research may help improve the malpractice system.
Shahian DM, Normand S-LT, Friedberg MW, et al. Ann Surg. 2016;264:36-8.
Public ratings of hospital quality and safety data may not always provide the best information for patients and clinicians. This commentary discusses problems with the existing set of patient safety metrics and suggests that measurement approaches need to be improved to enhance transparency and decision making.
… Second, some have warned that the United States faces a looming shortage of physicians. Better professional … the same physicians who reported the original problem. … MarkFriedberg, MD, MPP … Senior Natural Scientist RAND … 2013. [Available at] 7. Wachter RM. The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's …
This piece highlights the importance of focusing on physician professional satisfaction as a way to determine potential patient safety hazards and improve health care quality.
Semigran HL, Linder JA, Gidengil C, et al. BMJ. 2015;351:h3480.
… of 23 publicly available services which aim to provide a diagnosis for specific symptoms or give a triage recommendation . The online services listed the … prior to their widespread implementation. … Semigran HL, Linder JA, Gidengil C, Mehrotra A. Evaluation of symptom …
Singer SJ, Nieva HR, Brede N, et al. Med Care. 2015;53:141-52.
… and existing safety processes. Administrators reported a lack of safety systems, consistent with prior discussion of … to manage their workload leads to safety problems, echoing a recent focus group study of physicians. Respondents also … opportunities to improve safety in primary care settings. A recent AHRQ WebM&M interview and perspective discuss …
Linder JA, Doctor JN, Friedberg MW, et al. JAMA Intern Med. 2014;174:2029-31.
Unnecessary prescribing of antibiotics for viral conditions can pose patient safety risks. This study found that primary care physicians are more likely to prescribe antibiotics inappropriately toward the end of their clinic session (late morning or late afternoon), which likely represents clinicians' decision fatigue.
Rothschild JM, Woolf S, Finn KM, et al. Jt Comm J Qual Patient Saf. 2008;34:417-25, 365.
… spurred by endorsements from prominent organizations and a Joint Commission National Patient Safety Goal . However, … medical center did not improve clinical outcomes over a 6-month follow-up period. This study is one of the few to …