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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 - 10 of 10 Results
Smith S, Snyder A, McMahon LF, et al. Health Aff (Millwood). 2018;37:1787-1796.
Hospital-acquired pressure ulcers (HAPUs) are considered a never event, represent a significant source of patient harm, and can result in loss of payment to hospitals. In this study, researchers analyzed administrative data from 3 states for 2009 to 2014. The HAPU incidence they found was about one-twentieth of the HAPU incidence detected using chart review. In addition, while both chart review data and administrative data showed a reduction in HAPU incidence for the study period, the decline using administrative data was almost entirely due to a decrease in the incidence of lower stage pressure ulcers. The authors suggest that using clinical data from chart review and taking ulcer severity into account may yield a more meaningful measurement strategy.
Brenner AT, Malo TL, Margolis M, et al. JAMA Intern Med. 2018;178:1311-1316.
Shared decision making (SDM) between clinicians and patients is an integral part of developing true patient-centered care. The principles of SDM are broadly applicable to most clinician–patient encounters, but they may be particularly important in making decisions where the risks and benefits to an individual patient are nuanced. One such example is screening for lung cancer using low-dose computed tomography (LDCT), which may benefit certain patients but also poses a risk of harm due to overdiagnosis. The Centers for Medicare and Medicaid Services mandates SDM using a formal decision aid for reimbursement for lung cancer screening. However, this analysis of transcribed conversations between physicians and patients found almost no use of SDM principles. In particular, physicians universally recommended screening with LDCT, failed to discuss the potential for overdiagnosis, and did not use decision aids or patient education materials. Although limited by a small sample size, this study raises the concern that structural barriers (such as lack of time with patients) and poor understanding of SDM may be exposing patients to harm through limited understanding of diagnostic testing decisions. A related commentary discusses the potential for overdiagnosis of lung cancer if LDCT is used without proper attention to SDM.
Meddings JA, Reichert H, Rogers MAM, et al. Ann Intern Med. 2012;157:305-12.
The Centers for Medicare and Medicaid Services (CMS) has not reimbursed hospitals for costs associated with certain preventable complications, including catheter–associated urinary tract infections (CAUTI), since 2008. This policy was controversial when implemented, although the actual financial implications to hospitals were unclear. This study from Michigan is one of the first to objectively assess the impact of the CMS policy and found very few cases where payment was denied due to a CAUTI. The incidence of CAUTI was much lower than expected, most likely due to inaccuracies in the billing claims databases used to identify CAUTI. As the accompanying editorial notes, prior research has also cast doubt on the suitability of administrative data for reliably identifying patient safety events.
Lafata JE, Simpkins J, Kaatz S, et al. Jt Comm J Qual Patient Saf. 2007;33:395-400.
Drug–drug interactions resulting in adverse drug events are common causes of preventable harm to patients. This study used retrospective medical record review to assess if physicians were aware of potential drug–drug interactions, and if so, if patient education was provided. Although physicians generally documented medication lists appropriately, patient education on the potential for drug interactions and their symptoms was generally not documented. Though lack of documentation does not always indicate lack of knowledge or inappropriate management, the study results raise the concern that patients may be left unaware of the risks of polypharmacy.
Wagner AK, Chan A, Dashevsky I, et al. Pharmacoepidemiol Drug Saf. 2006;15:369-86.
This AHRQ-funded study discovered that 40% of patients received a medication that carried a potential for serious harm, classified by an FDA black box warning (BBW). Using a retrospective method to analyze nearly 1 million automated claims data, investigators determined the above prescribing rate for 216 specific BBW drugs in diverse ambulatory settings. While the authors acknowledge significant variability in compliance with BBW medications, the warnings themselves failed to prevent their use in many circumstances. Additional systems need to complement the BBW labeling practice, as certain clinical situations may lead to a lack of compliance with such guidelines. Improved information about risk, determination of risk, and methods to modify prescribing behavior will move clinicians closer to desired goals of medication safety.