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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 111 Results
Sokol-Hessner L, Dechen T, Folcarelli P, et al. Jt Comm J Qual Patient Saf. 2024;Epub Mar 7.
Medical errors can cause physical, financial, or emotional harm to patients. This survey identified prolonged emotional impacts (greater than one year) among the majority of US adults who experienced a medical error. Survey respondents who were female or with a lower socioeconomic status were more likely to report prolonged emotional impacts; organizational factors such as lack of organizational disclosure guidelines and no patient or family reporting process also increased risk of prolonged emotional impacts.
Liu SK, Bourgeois FC, Dong J, et al. Diagnosis (Berl). 2024;11:63-72.
Patient feedback on diagnostic errors may improve the quality and safety of care. As part of the larger OurDx study, this analysis examined patient feedback on what went well with the diagnostic process. Results mirrored those of studies on diagnostic errors, stating feeling heard, appreciated, and timely communication contributed to a good diagnostic process.
Bell SK, Amat MJ, Anderson TS, et al. J Am Med Inform Assoc. 2024;31:622-630.
Prompt completion of diagnostic tests or referrals is paramount to receiving a timely diagnosis and treatment. In this study, completion rates for three common diagnostic tests or referrals (i.e., colonoscopy, concerning skin lesions, cardiac stress test) were compared between patients who do not access a patient portal; patients who do have access but do not read visit notes; and patients who have access and who do read visit notes. Completion rates were highest for patients who read visit notes (62%) compared with those who do not read notes (57%) and those with no portal use (54%). The authors state timely completion rates for all groups remain below recommend thresholds and increased patient engagement is required.
Bell SK, Harcourt K, Dong J, et al. BMJ Qual Saf. 2023;Epub Aug 21.
Patient and family engagement is essential to effective and safe diagnosis. OurDX is a previsit online engagement tool to help identify opportunities to improve diagnostic safety in patients and families living with chronic conditions. In this study, researchers implemented OurDX in specialty and primary care clinics at two academic healthcare organizations and examined the potential safety issues and whether patient/family contributions were integrated into the post-visit notes. Qualitative analysis of 450 OurDX reports found that participants contributed important information about the diagnostic process. Participants with diagnostic concerns were more likely to raise concerns about the diagnostic process (e.g., access barriers, problems with tests/referrals, communication breakdowns), which may represent diagnostic blind spots.
Bell SK, Dong ZJ, DesRoches CM, et al. J Am Med Inform Assoc. 2023;30:692-702.
Patients and families are encouraged to play an active role in patient safety by, for example, reporting inaccurate or incomplete electronic health record notes after visits. In this study, patients and families at two US healthcare sites (pediatric subspecialty and adult primary care) were invited to complete a survey (OurDX) before their visit to identify their visit priority, recent medical history/symptoms, and potential diagnostic concerns. In total, 7.5% of patients and families reported a potential diagnostic concern, mainly not feeling heard by their provider.
Classen DC, Longhurst CA, Thomas EJ. NPJ Digit Med. 2023;6:2.
Artificial Intelligence (AI) is used in an increasing range of health care situations to address a variety of care needs. This commentary examines the impact of AI on patient safety, in diagnosis, and on the limitations of AI that affect reliability.
Bell SK, Bourgeois FC, Dong J, et al. Milbank Q. 2022;100:1121-1165.
Patients who access their electronic health record (EHR) through a patient portal have identified clinically relevant errors such as allergies, medications, or diagnostic errors. This study focused on patient-identified diagnostic safety blind spots in ambulatory care clinical notes. The largest category of blind spots was diagnostic misalignment. Many patients indicated they reported the errors to the clinicians, suggesting shared notes may increase patient and family engagement in safety.
Stockwell DC, Kayes DC, Thomas EJ. J Patient Saf. 2022;18:e877-e882.
Striving for “zero harm” in healthcare has been advocated as a patient safety goal. In this article, the authors discuss the unintended consequences of “zero harm” goals and provide an alternative approach emphasizing learning and resilience goals (leveled-target goal setting, equal emphasis goals, data-driven learning, and developmental) rather than performance goals.
Navathe AS, Liao JM, Yan XS, et al. Health Aff (Millwood). 2022;41:424-433.
Opioid overdose and misuse continues to be a major public health concern with numerous policy- and organization-level approaches to encourage appropriate clinician prescribing. A northern California health system studied the effects of three interventions (individual audit feedback, peer comparison, both combined) as compared to usual care at several emergency department and urgent care sites. Peer comparison and the combined interventions resulted in a significant decrease in pills per prescription.
Nether KG, Thomas EJ, Khan A, et al. J Healthc Qual. 2022;44:23-30.
Medical errors in the neonatal intensive care unit threaten patient safety. This children’s hospital implemented a robust process improvement program (RPI, which refers to widespread dissemination of process improvement tools to support staff skill development and identify sustainable improvements) to reduce harm in the neonatal intensive care unit. The program resulted in significant and sustainable improvements to staff confidence and knowledge related to RPI tools. It also contributed to improvements in health outcomes, including healthcare-acquired infection.
Shafer GJ, Singh H, Thomas EJ, et al. J Perinatol. 2022;42:1312-1318.
Patients in the neonatal intensive care unit (NICU) are at risk for serious patient safety threats. In this retrospective review of 600 consecutive inborn NICU admissions, researchers found that the frequency of diagnostic errors among inborn NICU patients during the first seven days of admission was 6.2%.
Bell SK, Dong J, Ngo L, et al. BMJ Qual Saf. 2023;32:644-654.
Limited English-language health literacy (LEHL) and disadvantaged socioeconomic position (dSEP) have been shown to increase risk of adverse events and near misses. Using data from the 2017 Institute for Healthcare Improvement-National Patient Safety Foundation study, researchers found, while respondents with LEHL or dSEP experienced diagnostic errors at the same rate as their counterparts, they were more likely to report unique contributing factors and more long-term emotional, physical, and financial harm.
Ranji SR, Thomas EJ. BMJ Qual Saf. 2022;31:255-258.
Diagnostic safety interventions have been empirically evaluated but real-world implementation challenges persist. This commentary discusses the importance of incorporating contextual factors (e.g., social, cultural) facing complex healthcare systems into the design of diagnostic safety interventions. The authors provide recommendations for designing studies to improve diagnosis that take contextual factors into consideration.
Loren DL, Lyerly AD, Lipira L, et al. J Patient Saf Risk Manag. 2021;26:200-206.
Effective communication between patients and providers – including after an adverse event – is essential for patient safety. This qualitative study identified unique challenges experienced by parents and providers when communicating about adverse birth outcomes – high expectations, powerful emotions, rapid change and progression, family involvement, multiple patients and providers involved, and litigious environment. The authors outline strategies recommended by parents and providers to address these challenges.
Bell SK, Bourgeois FC, DesRoches CM, et al. BMJ Qual Saf. 2022;31:526-540.
Engaging patients and families in their own care can improve outcomes, safety, and satisfaction. This study brought patients, families, clinicians and experts together to identify patient-reported diagnostic process-related breakdowns. The group identified 7 categories, 40 subcategories, 19 contributing factors and 11 patient-reported impacts. Breakdowns were identified in each step of the diagnostic process.
Bisbey TM, Kilcullen MP, Thomas EJ, et al. Hum Factors. 2021;63:88-110.
A culture of safety is a key component to successful, sustainable patient safety programs. The authors review existing models of safety culture and propose a framework which synthesizes information across fragmented concepts – including organizational culture, social identity, and social learning – to illustrate the dynamic nature and drivers of safety culture.
Lam BD, Bourgeois FC, Dong ZJ, et al. J Am Med Inform Assoc. 2021;28:685-694.
Providing patients access to their medical records can improve patient engagement and error identification. A survey of patients and families found that about half of adult patients and pediatric families who perceived a serious mistake in their ambulatory care notes reported it, but identified several barriers to reporting (e.g. no clear reporting mechanism, lack of perceived support).  
Kesselheim JC, Shelburne JT, Bell SK, et al. Acad Pediatr. 2021;21:352-357.
This article reports findings from a survey of pediatric trainees at two large children’s hospitals on attitudes and behaviors in regard to speaking up about traditional safety threats and unprofessional behavior. While trainees more commonly observed unprofessional behavior than safety threats, they are less likely to speak up when presented with unprofessional behavior.
Wu AW, Buckle P, Haut ER, et al. J Patient Saf Risk Manag. 2020;25:93-96.
This editorial discusses priority areas for maintaining and promoting the well-being of the healthcare workforce during the COVID-19 pandemic. The authors discuss the importance of providing adequate personal protective equipment (PPE), supporting basic daily needs (e.g., provision of in-hospital food stores), ensuring frequent and visible communication, supporting mental and emotional well-being, addressing ethical concerns, promoting wellness, and showing gratitude for staff.