Skip to main content

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.

Search All Content

Search Tips
Filter By Author(s)
Advanced Filtering Mode
Date Ranges
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Additional Filters
Approach to Improving Safety
Displaying 1 - 20 of 21 Results
Auerbach AD, Astik GJ, O’Leary KJ, et al. J Gen Intern Med. 2023;38:1902-1910.
COVID-19 ushered in new diagnostic challenges and changes in care practices. In this study conducted during the first wave of the pandemic, charts for hospitalized adult patients under investigation (PUI) for COVID-19 were reviewed for potential diagnostic error. Diagnostic errors were identified in 14% of cases; patients with and without diagnostic errors were statistically similar and errors were not associated with pandemic-related change practices.
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.
Raffel KE, Kantor MA, Barish P, et al. BMJ Qual Saf. 2020;29:971-979.
This retrospective cohort study characterized diagnostic errors among adult patients readmitted to the hospital within 7 days of hospital discharge. Over a 12-month period, 5.6% of readmissions were found to contain at least one diagnostic error during the index admissions. These diagnostic errors were primarily related to clinician diagnostic reasoning, including failure to order needed tests, erroneous interpretation of tests, and failure to consider the correct diagnosis. The majority of the diagnostic errors resulted in some form of clinical impact, including short-term morbidity and readmissions.
Perspective on Safety September 1, 2019
… with the 1999  To Err Is Human  report, there was a recognition that preventing harm would require more than … the 20 key resources. Our PSNet clinician editors are Sumant Ranji, Kiran Gupta, Urmimala Sarkar, Audrey Lyndon, … San Francisco … Sumant … Robert … Ranji … Wachter … R. … Sumant R. Ranji … Robert Wachter …
This piece explores the evolution of PSNet and WebM&M since their inception (WebM&M in 2003 and PSNet in 2005) and summarizes changes in the patient safety landscape over time.
Shaikh U, Afsar-Manesh N, Amin AN, et al. Int J Qual Health Care. 2017;29:735-739.
Health care institutions are increasingly focused on teaching quality improvement and patient safety to both faculty and trainees. This study describes the implementation of an online course comprised of three quizzes to teach important concepts related to quality improvement, patient safety, and care transitions across five academic medical centers.
Duong JA, Jensen TP, Morduchowicz S, et al. J Gen Intern Med. 2017;32:654-659.
Patients hospitalized and cared for by an overnight physician, known as "holdover admissions," are increasingly common due to duty hours limitations, and they necessitate handoffs between admitting physicians and the new primary medical team. This qualitative study identified unmet needs in holdover handoffs, including assessment of diagnostic uncertainty, standardization, and feedback. The authors call for more scrutiny of holdover handoffs.
Perspective on Safety January 1, 2017
… 2017 … Introduction … Anyone who has spent time in a hospital as a patient or staff member may recognize that … associated with weekend admissions to hospital. … SumantRanjiR. … Sumant R. Ranji
A considerable body of evidence demonstrates worsened clinical outcomes for patients admitted to the hospital on weekends compared to those admitted on weekdays. This Annual Perspective summarizes innovative studies published in 2017 that helped clarify the magnitude of this effect and identify possible mechanisms by which it occurs.
Perspective on Safety March 22, 2016
The toll of medical errors is often expressed in terms of mortality attributable to patient safety problems. In 2016, there was considerable debate regarding the number of patients who die due to medical errors. This Annual Perspective explores the methodological approaches to estimating mortality attributable to preventable adverse events and discusses the benefits and limitations of existing approaches.
The toll of medical errors is often expressed in terms of mortality attributable to patient safety problems. In 2016, there was considerable debate regarding the number of patients who die due to medical errors. This Annual Perspective explores the methodological approaches to estimating mortality attributable to preventable adverse events and discusses the benefits and limitations of existing approaches.
Kantor MA, Evans KH, Shieh L. J Gen Intern Med. 2015;30:312-8.
In this single-site study, 70% of patients discharged from a general medicine service had at least one pending test result. The introduction of a tool that automatically generates a list of studies pending at discharge improved communication of pending studies from 18% to 43%.
Ranji SR, Rennke S, Wachter R. BMJ Qual Saf. 2014;23:773-80.
This narrative review found that while computerized provider order entry combined with clinical decision support systems effectively prevented medication prescribing errors, there was no clear effect on clinical adverse drug event rates. This finding may be due to alert fatigue and other unintended consequences of the technology.
Perspective on Safety January 1, 2014
… focus on medical knowledge and technical skills to a curriculum integrating systems analysis , quality … … SumantRanjiR. … Sumant R. Ranji … Editor's note: … … and an Associate Professor of Medicine at the Michael E. DeBakey VA Medical Center and Baylor College of Medicine. …
Dr. Singh has conducted extensive multidisciplinary research supported by the VA, AHRQ, and NIH and is now a nationally recognized expert in electronic health record–related patient safety issues and diagnostic errors. We spoke with him about becoming a patient safety researcher.
Mookherjee S, Vidyarthi AR, Ranji SR, et al. J Gen Intern Med. 2010;25.
… Journal of General Internal Medicine … J Gen Intern Med … A 2008 policy change by the Centers for Medicare and Medicaid … policy's impact on clinical practice among trainees. In a series of presented clinical vignettes, members of the …
Wood KA, Ranji SR, Ide B, et al. Jt Comm J Qual Patient Saf. 2009;35:475-82, 437.
This survey characterizes the types of rapid response systems in academic tertiary care hospitals in the United States and discusses barriers to implementation as well as successes achieved by the teams.
WebM&M Case April 1, 2008
A woman with symptoms of sinusitis was given 2 different courses of broad-spectrum antibiotics, neither of which improved her symptoms. Hospitalized for autoimmune hemolysis (presumably from the antibiotic), the patient suffered multiorgan failure and septic shock, and died.
Ranji SR, Shojania KG. Med Clin North Am. 2008;92:275-93, vii-viii.
Patient safety improvement initiatives are often chosen in the context of an existing tension between taking an evidence-based approach versus a practical one. This commentary provides a framework for choosing various interventions with a particular focus on what hospitalists should target for implementation. The authors advocate for a "balanced diet" approach in combining: (1) important practices with strong evidence (e.g., prevention of catheter-related blood stream infections), (2) momentum-generating projects (e.g., executive walk rounds), and (3) system-level interventions (e.g., computerized physician order entry [CPOE]). A previous AHRQ WebM&M perspective addresses how to interpret the patient safety literature.