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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 - 13 of 13 Results
Chopra V, O'Malley M, Horowitz J, et al. BMJ Qual Saf. 2022;31:23-30.
Peripherally inserted central catheters (PICC) represent a key source of preventable harm. Using the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC), the authors sought to determine if the appropriateness of PICC use decreased related medical complications including catheter occlusion, venous thromboembolism, and central line-associated bloodstream infections. Use of MAGIC in 52 Michigan hospitals increased appropriate use of PICC lines and decreased medical complications. In a 2019 PSNet Perspective, Dr. Vineet Chopra described the development and implementation of MAGIC in Michigan hospitals.  
WebM&M Case February 1, 2019
A woman was admitted to a hospital's telemetry floor for management of uncontrolled hypertension and palpitations. On the first hospital day, she complained of right arm numbness and weakness and had new difficulty answering questions. The nurse called the hospitalist and relayed the arm symptoms, but not the word-finding difficulty. The hospitalist asked the nurse to call for a neurology consultation. Four hours later, the patient's weakness had progressed; she was now completely unable to move her right arm.
Gupta A, Snyder A, Kachalia A, et al. BMJ Qual Saf. 2017;27:53-60.
Characterization of diagnostic error in the hospital setting has traditionally relied on data from autopsy studies, but the continuing decline in autopsy rates necessitates identification of diagnostic errors through other data sources. In this study, investigators utilized the National Practitioner Data Bank to examine the incidence and severity of inpatient diagnostic error and estimate the clinical and economic consequences of these errors. Diagnostic error accounted for 22% of paid malpractice claims over a 12-year period, resulting in $5.7 billion in payments, and the incidence of claims due to failure to diagnose increased over time. Paid claims due to diagnostic error were more likely to be for male patients older than 50, compared with other types of paid claims. Consistent with other studies, a small proportion (9%) of physicians accounted for a large proportion (51%) of payments. Although paid malpractice claims data have important limitations, this study advances our understanding of the epidemiology of diagnostic error among hospitalized patients and insights into possible preventive mechanisms.
Auerbach AD, Kripalani S, Vasilevskis EE, et al. JAMA Intern Med. 2016;176:484-93.
Preventing readmissions is a cornerstone of patient safety efforts. However, one concern about nonpayment for readmissions is that many may not be preventable. To determine whether they were preventable, this observational study investigated readmissions through patient and physician surveys along with chart review. Researchers determined that only one quarter of readmissions were preventable. Factors associated with potential preventability were premature hospital discharge, insufficient communication with outpatient providers, failure to discuss care goals, and emergency department decisions to readmit a patient who did not require a second inpatient stay. These results suggest that multiple interventions will be needed to avert readmissions, and such efforts will have limited impact since most readmissions are not preventable.
Saint S, Fowler KE, Krein SL, et al. Infect Control Hosp Epidemiol. 2015;36:969-971.
Clostridium difficile infections are among the most serious health care–associated infections. In this study, most hospitals in the United States reported using C. difficile prevention measures, with the exception of antibiotic stewardship, which was in place at about half of hospitals surveyed. This finding underscores the need to focus on appropriate antibiotic use as part of patient safety efforts.
WebM&M Case November 1, 2012
A 32-year-old man went to the emergency department with fever and pleuritic chest pain. Following an extensive work-up, he was discharged with "fever, pleural effusion, and chest wall pain", but no clear diagnosis. He returned to the ED 3 days later with worsening pain, continued fever, a new cough, and dyspnea. The patient was started on antibiotics and admitted for pneumonia with effusion.
Walker PC, Bernstein SJ, Jones JNT, et al. Arch Intern Med. 2009;169:2003-10.
Medication errors are a leading contributor to adverse events after hospital discharge, and prior studies have demonstrated a high incidence of inadvertent medication discrepancies at the time of discharge. Pharmacist involvement in inpatient care is a proven strategy to improve safety, and a pharmacist-led medication reconciliation and education process successfully reduced medication errors and hospital readmissions in a prior study. In this trial, while the involvement of a pharmacist in medication teaching, medication reconciliation, communication of medication changes to outpatient physicians, and post-discharge telephone follow-up with patients did appear to reduce medication discrepancies, it had no impact on rates of readmissions and emergency department visits. This finding may indicate that more comprehensive discharge interventions may be necessary in order to reduce the risk of readmission.
Perspective on Safety September 1, 2005
… of the Matter " (June 2005) Letter To the editors: In Drs. Flanders and Saint's otherwise superb summary and review of … involved in the error prior to final implementation. … Scott A. Flanders, MD … University of Michigan School of … of Michigan School of Medicine … Louise … Sanjay … Scott … Mark … Grondin … Saint … Flanders … Williams … Louise …
In Drs. Flanders and Saint’s otherwise superb summary and review of the use of root cause analysis to identify systems’ vulnerabilities and improve overall patient care delivery, I was surprised by their statement that RCAs are “performed by a team with...