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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 30 Results
Wiegand AA, Sheikh T, Zannath F, et al. BMJ Qual Saf. 2023;Epub May 10.
Sexual and gender minority (SGM) patients may experience poor quality of healthcare due to stigma and discrimination. This qualitative study explored diagnostic challenges and the impact of diagnostic errors among 20 participants identifying as sexual minorities and/or gender minorities. Participants attribute diagnostic error to provider-level and personal challenges and how diagnostic error worsened health outcomes and led to disengagement from healthcare. The authors of this article also summarize patient-proposed solutions to diagnostic error through the use of inclusive language, increasing education and training on SGM topics, and inclusion of more SGM individuals in healthcare.
Wiegand AA, Dukhanin V, Sheikh T, et al. Diagnosis (Berl). 2022;9:458-467.
Previous research has identified gender and racial disparities in the burden of diagnostic errors. In this study, researchers conducted a series of human-centered design workshops with a diverse set of stakeholders who generated a set of design challenges, principles, and solutions for addressing diagnostic disparities, improving healthcare quality, and promoting equity and inclusion of marginalized patients. Participants also identified two prototypes for the solutions – a visit preparation guide to teach patients how to advocate for themselves and a tool for identifying patients who may be at increased risk for experiencing a diagnostic error.
Zrelak PA, Utter GH, McDonald KM, et al. Health Serv Res. 2022;57:654-667.
The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) are widely used for measuring and reporting hospital quality and patient safety. This paper describes the process of reweighing the composite patient safety indicator (PSI 90) to incorporate excess harm reflecting patients’ preferences for various possible related outcomes (e.g., readmissions, reoperation, long-term care stay, death). Compared to the original frequency-based weighting, some component indicators in the reweighted composite – including postoperative respiratory failure, postoperative sepsis, and perioperative pulmonary embolism or deep vein thrombosis – contributed to the greatest harm.
Yousef EA, Sutcliffe KM, McDonald KM, et al. Hum Factors. 2022;64:6-20.
Safe diagnosis is a complex challenge requiring multidisciplinary approaches. The authors of this article apply high-reliability organization principles to the National Academy of Medicine (NAM) diagnostic process. The goal was to identify diagnostic challenges as well as strategies and solutions that diagnostic teams and organizations can use to optimize the diagnostic process and improve patient outcomes.
Lyson HC, Sharma AE, Cherian R, et al. J Patient Saf. 2021;17:e335-e342.
This study used direct observation and interviews to assess hazards in the medication use process in a sample of ambulatory patients who predominantly had low health literacy. The investigators found that the outpatient medication use process is fragmented and complex with poor coordination between clinicians, pharmacists, and insurance companies, forcing patients to develop self-management strategies to manage their chronic health conditions.
Sarkar U, McDonald KM, Motala A, et al. Jt Comm J Qual Patient Saf. 2017;43:661-670.
Patient safety in the ambulatory setting is gaining traction as a focus of research and improvement efforts. Discussing the methods and results of an AHRQ Technical Brief, this commentary summarizes expert opinion on the report to propose recommendations for a research strategy on ambulatory patient safety. The authors outline patient safety practices relevant to the ambulatory setting and suggest activities to advance improvement efforts in outpatient care, such as measure development and use of health information technologies.
Tedesco D, Asch SM, Curtin C, et al. Health Aff (Millwood). 2017;36:1748-1753.
Using data from the Healthcare Cost and Utilization Project, this retrospective secondary data analysis found an overall increase in opioid-related hospital visits, with a peak in 2010 and gradual decline since then. Coincident with the decline in opioid-related visits, a sharp rise in heroin-related hospital visits emerged. These results underscore the concern that tighter controls on opioid medications may lead to heroin use.
McDonald KM, Su G, Lisker S, et al. Implement Sci. 2017;12:79.
Diagnostic error in the ambulatory care setting is common, particularly with regard to missed or delayed diagnoses of cancer. This study used human factors engineering and design thinking approaches to develop an understanding of how ambulatory specialists monitor patients with high-risk conditions and to identify vulnerabilities in the monitoring process that could lead to delayed diagnoses.
Moghavem N, McDonald KM, Ratliff JK, et al. Med Care. 2016;54:359-64.
The AHRQ Patient Safety Indicators (PSIs) can identify adverse events in hospital data. This study demonstrated that PSIs were associated with longer hospital stays and increased mortality. Neurosurgery patients were more likely to have PSIs occur than other surgical patients.
McGlynn EA, McDonald KM, Cassel C. JAMA. 2015;314:2501-2502.
Measurement in patient safety is challenging and requires consensus to determine the presence of specific problems. In light of recommendations from the Improving Diagnosis in Health Care report, this commentary reviews five purposes for measuring diagnostic errors: determining the extent of diagnostic errors; understanding their underlying causes; measuring whether interventions work; skill assessment for training and education; and tracking performance. The authors describe how achieving each of these goals will require distinct strategies. A PSNet interview with Hardeep Singh discussed issues of measurement in diagnosis.
Davies SM, Saynina O, Baker LC, et al. Am J Med Qual. 2015;30:114-8.
The AHRQ Patient Safety Indicators (PSIs) do not include adverse events after hospital discharge, which could introduce bias into measurement of safety events at the individual hospital level. However, this study found that inclusion of postdischarge adverse events in PSI calculations did not significantly change comparisons of safety between hospitals or within the same hospital over time.
Hernandez-Boussard T, McDonald KM, Rhoads KF, et al. Ann Plast Surg. 2015;74:597-602.
Using AHRQ patient safety indicators, this study established that approximately 4% of plastic surgery patients experience an adverse event during their hospital stay. This rate is relatively low compared with other surgical disciplines, but it is significant due to the proportion of young healthy patients who undergo plastic surgery.
McDonald KM, Bryce CL, Graber ML. BMJ Qual Saf. 2013;22 Suppl 2:ii33-ii39.
Diagnostic errors are increasingly recognized as an important—and costly—aspect of patient safety. This study advocates for engaging patients to improve diagnostic accuracy in their care and provides tactics to help patients prevent diagnostic errors, including a list of questions to ask their provider. These approaches aim to enhance clinician–patient communication and to help physicians avoid their own cognitive biases. The article also argues for the role of patients as a "crucial voice" in augmenting diagnostic delivery systems, research, and policy. A previous AHRQ WebM&M perspective with Dr. Mark Graber discussed diagnostic errors along with strategies for clinicians to avert cognitive pitfalls.
Shekelle PG, Pronovost P, Wachter R, et al. Ann Intern Med. 2013;158:365-8.
Progress in patient safety improvement has been hindered by a lack of high-quality research on error prevention, poor understanding of how context influences safety strategies, and insufficient information on how best to implement evidence-based safety strategies. The Agency for Healthcare Research and Quality funded a multi-institutional effort to address these challenges, which culminated in the release of the Making Health Care Safer II report. Detailing methodology that the report's authors used to systematically review the evidence on effectiveness, context, and implementation for 41 key safety strategies, this commentary presents 10 strategies considered ready for widespread implementation. These strategies—including checklists to prevent certain health care–associated infections and surgical complications, bundled interventions to reduce falls and pressure ulcers, and interventions to decrease medication errors and improve hand hygiene—are all considered to have strong evidence of effectiveness, minimal potential for adverse consequences, and be reasonably easy to implement. This commentary is part of a special patient safety supplement in the Annals of Internal Medicine.
Hernandez-Boussard T, McDonald KM, Morton J, et al. J Am Coll Surg. 2012;214:788-97.
Vascular surgery is considered a higher risk surgical specialty, as many patients undergoing vascular procedures are elderly and have other comorbid illnesses, putting them at elevated risk of postoperative complications. This study used Patient Safety Indicators (PSIs) to analyze more than 1.4 million patients who underwent vascular surgery from 2005–2009 and found that more than 5% experienced a postoperative adverse event. Procedural complexity and comorbidities were associated with increased risk of a PSI, corroborating prior studies that have found a link between illness severity and risk of complications in medical patients. The PSIs are best used to screen administrative data for potential adverse events, as in this study. In surgical patients, the National Surgical Quality Improvement Program measures have been shown to be superior for accurate detection of postoperative adverse events.
Hernandez-Boussard T, Downey JR, McDonald KM, et al. Health Serv Res. 2011;47.
Studying the relationship between hospital volume, surgical volume, and clinical outcomes, past research in part led to recommendations for volume-based referral as a safety practice. However, the volume–outcome relationship may be limited to selected surgical procedures, suggesting that systematic volume-based referral is unnecessary. This study further examines these relationships by evaluating the impact of hospital surgical volume on preventable adverse events. The latter were measured using the AHRQ Patient Safety Indicators (PSIs), which have noted limitations as measures of safety. Nevertheless, investigators found that hospital volume for abdominal aortic aneurysm, coronary bypass graft, and Roux-en-Y gastric bypass were inversely related to PSI rates. Additional research to further evaluate the structural and process differences between outcomes and hospital volume may help identify potential safety solutions.