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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 36 Results
Kapoor A, Patel P, Mbusa D, et al. J Gen Intern Med. 2023;Epub Sep 27.
Pharmacists are frequently involved in medication reviews for hospitalized patients prescribed direct oral anti-coagulants (DOAC). This randomized controlled study explored pharmacist involvement with patients prescribed DOAC in ambulatory care. The intervention included up to three phone calls, electronic health record communication with the prescriber, and recommendations for lab work. After 90 days, there were no differences in clinically important medication errors between groups.
White AA, King AM, D’Addario AE, et al. JMIR Med Educ. 2022;8:e30988.
Communication with patients and caregivers is important after a diagnostic error. Using a simulated case involving delayed diagnosis of breast cancer, this study compared how crowdsourced laypeople and patient advocates rate physician disclosure communication skills. Findings suggest that patient advocates rate communication skills more stringently than laypeople, but laypeople can correctly identify physicians with high and low communication skills.
Mazor KM, Kamineni A, Roblin DW, et al. J Patient Saf. 2021;17:e1278-e1284.
Patient engagement and encouraging speaking up can promote safety. This randomized study found that patients undergoing cancer treatment who were randomized to an active outreach program were significantly more likely to speak up and report healthcare concerns than patients in the control group.
Field TS, Fouayzi H, Crawford S, et al. J Am Med Dir Assoc. 2021;22:2196-2200.
Transitioning from hospital to nursing home (NH) can be a vulnerable time for patients. This study looked for potential associations between adverse events (AE) for NH residents following hospital discharge and NH facility characteristics (e.g., 5-star quality rating, ownership, bed size). Researchers found few associations with individual quality indicators and no association between the 5-star quality rating or composite quality score. Future research to reduce AEs during transition from hospital to NH should look beyond currently available quality measures.
Gurwitz JH, Kapoor A, Garber L, et al. JAMA Intern Med. 2021;181:610-618.
High-risk medications have the potential to cause serious patient harm if not administered correctly. In this randomized trial, a pharmacist-directed intervention (including in-home assessment by a clinical pharmacist, communication with the primary care team, and telephone follow-up) did not result in a lower rate of adverse drug events or medication errors involving high-risk drug classes during the posthospitalization period.
Street RL, Petrocelli JV, Amroze A, et al. J Patient Exp. 2020;7:1247-1254.
Patient and family engagement play a critical role in patient safety. This study found that patient and family members perceived that information inadequacy, not listening, and dismissive behavior contributed to communication breakdowns that led to medical errors or close calls. These findings underline the critical role of patient and family engagement to prevent errors and improve care delivery.  
White AA, Sage WM, Mazor KM, et al. Jt Comm J Qual Patient Saf. 2020;46:591-595.
This commentary discusses safety outcomes associated with late career practitioners, measuring practitioner performance, and options for practitioners with declining performance, including key features and lessons learned from early adopters of late career practitioner programs.
Fisher KA, Smith KM, Gallagher TH, et al. Jt Comm J Qual Patient Saf. 2020;46:261-269.
This article evaluates the implementation of the We Want to Know program, which encourages hospitalized patients to speak up about breakdowns in care. Over a three-year period at one large, community hospital, the program interviewed over 4,600 patients and identified 822 (17.6%) who experienced a breakdown in care. Of those, 66.5% identified harm associated with the incident and 61.9% had spoken to someone at the hospital about it. Stakeholders (e.g., nurses, nurse managers, physicians, hospital administrators and leadership) found the program reports provided timely, actionable information and allowed for real-time responses and resolutions. Concerns cited by stakeholders included overlap with exiting patient safety reporting efforts, high level of effort and resources required, ensuring adequate responses.
Kapoor A, Field T, Handler S, et al. JAMA Intern Med. 2019;179:1254-1261.
Transitions from hospitals to long-term care facilities are associated with safety hazards. This prospective cohort study identified adverse events in the 45 days following acute hospitalization among 555 nursing home residents, which included 762 discharges during the study period. Investigators found that adverse events occurred after approximately half of discharges. Common adverse events included falls, pressure ulcers, health care–associated infections, and adverse drug events. Most adverse events were deemed preventable or ameliorable. The authors conclude that improved communication and coordination between discharging hospitals and receiving long term-care facilities are urgently needed to address this patient safety gap. A previous WebM&M commentary discussed challenges of nursing home care that may contribute to adverse events.
Fisher K, Smith KM, Gallagher TH, et al. BMJ Qual Saf. 2019;28:190-197.
Patients are frequently encouraged to engage with health care providers as partners in safety by speaking up and sharing their concerns. Although research has shown that patients and family members sometimes identify safety issues that might otherwise go unnoticed, they may not always be willing to speak up. In this cross-sectional study involving eight hospitals, researchers used postdischarge patient survey data to understand patients' comfort in voicing concerns related to their care. Almost 50% of the 10,212 patients who responded to the survey reported experiencing a problem during hospitalization, and 30% of those patients did not always feel comfortable sharing their concerns. An Annual Perspective summarized approaches to engaging patients and caregivers in safety efforts.
Cutrona SL, Fouayzi H, Burns L, et al. J Gen Intern Med. 2017;32:1210-1219.
Electronic health record alerts contribute to alert fatigue and increase provider workload. Some alerts are more time-sensitive than others and a delayed response can adversely impact patient safety. This study found that time-sensitive alerts were less likely to be opened by primary care providers within 24 hours if the provider's InBasket had a high number of notifications at the time of alert delivery or if the alert was sent on the weekend.
Walsh KE, Harik P, Mazor KM, et al. Med Care. 2017;55:436-441.
Determining the severity of harm or potential harm is a challenge in patient safety. Investigators asked physicians, nurses, and pharmacists to rate the severity of harm for specific adverse events including falls, health care–associated infections, pressure ulcers, and blood product errors. The authors recommend using two raters to determine harm in order to achieve reliable estimates.
Fisher K, Ahmad S, Jackson M, et al. Patient Educ Couns. 2016;99:1685-93.
This qualitative study used in-depth interviews with family members of critically ill patients to assess their perception of safety and quality problems. Nearly half of surrogate decision makers identified at least one safety concern, most often relating to communication from clinicians. Patient and family identification of errors is an important strategy for engaging patients in safety efforts.
Mazor KM, Smith KM, Fisher K, et al. Ann Intern Med. 2016;164:618-9.
Although patients have been increasingly encouraged to speak up about concerns as a way to improve safety, health care institutions often have no system in place to ensure such concerns are promptly addressed. This commentary explores the disconnect between intention and action and suggests steps to be taken so that health systems can achieve benefits of patient engagement initiatives.
Mazor KM, Roblin DW, Greene SM, et al. BMJ Qual Saf. 2016;25:787-95.
Despite widespread calls for full disclosure of medical errors, physicians often choose their words carefully rather than explicitly detail how errors may have occurred. This study used two hypothetical vignettes to explore primary care providers' willingness to disclose errors involving multiple providers. The first vignette included a diagnosis of breast cancer that may have been delayed due to miscommunication with a covering physician. The second vignette described a breakdown in care coordination between providers responding to a patient's telephone call concerns, resulting in an adverse outcome. The majority of respondents said they would provide only a partial disclosure in either situation. More than three-quarters of physicians in the breast cancer case said they would offer either no information or would make vague references to miscommunication. In a prior WebM&M interview, Dr. Thomas Gallagher, the senior author of this study, discussed error disclosure.
Prouty CD, Mazor KM, Greene SM, et al. J Gen Intern Med. 2014;29:1122-30.
Quality cancer care is often threatened by poor communication and lack of coordination. Prior research has described cancer patients' perspectives related to communication breakdowns, but this study used focus groups with primary care physicians, oncologists, and nurses to explore the clinician viewpoint. Many insightful quotes are included throughout the article illustrating complex interchanges between patients, providers, and health systems in the high-stakes arena of longitudinal cancer care. One highlighted problem related to some patients' reticence to discuss adverse effects of therapy due to fear that they will no longer be offered further treatments. Clinicians often found it challenging to balance hope with reality and to provide accurate information to patients and their families. They also expressed frustration with systems factors, such as appointments that are too short for having serious in-depth conversations. The authors suggest a number of potential solutions for facilitating open communication between patients and providers.
Gallagher TH, Mello MM, Levinson W, et al. N Engl J Med. 2013;369:1752-7.
Physicians are notably loath to fully disclose their own errors, but some progress is being made in this area due to institutional policies supporting error disclosure. This article is intended to foster discussion of an especially thorny issue: how clinicians should approach error disclosure when the error was committed by a colleague. As little prior literature exists regarding this dilemma, the authors emphasize a patient-centered approach that begins with a respectful peer-to-peer conversation and does not shirk the need to fully disclose the error. The importance of institutional support, particularly in establishing a just culture that promotes error disclosure, is also emphasized. The article's lead author, Dr. Thomas Gallagher, was interviewed by AHRQ WebM&M in 2009.
Walsh KE, Roblin DW, Weingart SN, et al. Pediatrics. 2013;131:e1405-14.
The ability to treat many types of cancer with oral chemotherapy has benefited patients by minimizing hospitalizations, but it also places the burden to avoid medication errors on them as they must administer risky medications correctly. Prior studies have shown that adults and children with cancer are particularly vulnerable to medication errors and that most oncology practices do not have specific safeguards in place to improve oral chemotherapy medication safety. This study used direct observation (during home visits) to determine the epidemiology of medication errors among children with cancer and found a staggeringly high incidence of 36 potentially harmful errors per 100 patients—higher than some studies of hospitalized patients. The authors judged that more than one-third of the errors could have been prevented by better communication between patients and physicians.