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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 26 Results
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.
Siewert B, Swedeen S, Brook OR, et al. Radiology. 2022;302:613-619.
Adverse events can contribute to physical, financial, or emotional harm. Based on radiology-related events identified in a hospital incident reporting system, the authors identified the types of incidents contributing to emotional harm in patients – failure to be patient-centered, disrespectful communication, privacy violations, minimization of patient concerns, and loss of property. The authors also proposed several improvement strategies, including communication training and improvement of communication processes, individual feedback, and improvements to existing processes and systems.
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.
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.
Auerbach AD, O'Leary KJ, Greysen SR, et al. J Hosp Med. 2020;15:483-488.
Based on a survey of hospital medicine groups at academic medical centers in the United States (conducted April 2020), the authors of this study characterized inpatient adaptations to care for non-ICU COVID-19 patients. Sites reported rapid expansion of respiratory isolation units (RIUs – dedicated units for patients with known or suspected COVID-19), an emphasis on telemedicine for patient evaluation, and implementation of approaches to minimize room entry. In addition, nearly half of responding sites reported diagnostic errors involving COVID-19 (missing non-COVID-19 diagnoses among infected patients and missing COVID-19 diagnoses in patients admitted for other reasons).
White AA, Sage WM, Osinska PH, et al. BMJ Qual Saf. 2019;28:468-475.
High reliability fields like aviation employ policies to require that professionals retire from risky work at a certain age. Researchers interviewed health care system leaders and other stakeholders to devise recommendations for managing physicians as they age. Respondents emphasized patient safety as a guiding principle in addressing aging physicians' performance.
Sokol-Hessner L, Folcarelli P, Annas CL, et al. Jt Comm J Qual Patient Saf. 2018;44:463-476.
… Commission journal on quality and patient safety … Jt Comm J Qual Patient Saf … Preventable harm encompasses both … and preventing emotional harm. Researchers convened a multidisciplinary expert group to identify best practices … patients , and supporting frontline staff. They provide a list of practical tactics to shift health care …
Brown SM, Azoulay E, Benoit D, et al. Am J Respir Crit Care Med. 2018;197:1389-1395.
… journal of respiratory and critical care medicine … Am J Respir Crit Care Med … This commentary explores the results of a multidisciplinary discussion on the intersection of " … care. The authors provide recommendations to encourage a strong system-level commitment to respect and dignity, …
Lucier D, Folcarelli P, Totte C, et al. Jt Comm J Qual Patient Saf. 2018;44:84-93.
Mortality reviews, in which all cases of in-hospital death are discussed in structured format, can detect patient safety problems. This study reports the results of a mortality review survey in hospital medicine and intensive care units at an academic medical center. The survey aimed to identify deaths that merited further investigation. Researchers identified five deaths that would not have come to light through other hospital case review mechanisms. Respondents expressed needs for both clinician support following patient deaths and greater advance care planning. The authors conclude that frontline care team surveys can augment existing hospital mortality review processes. Previous WebM&M commentaries have highlighted the importance of advance care planning, particularly for seriously ill older patients and those with advanced dementia.
Khan A, Coffey M, Litterer KP, et al. JAMA Pediatr. 2017;171:372-381.
Detecting adverse events remains a challenge across health care settings. This prospective study conducted in multiple pediatric inpatient settings used medical record review, clinician reports, and hospital incident reports to identify adverse events. Investigators compared adverse events detected with these mechanisms to adverse events identified through interviews with parents and caregivers of pediatric patients. As with previous studies, two physicians reviewed all incidents and rated the severity and preventability of all incidents. About half the incidents reported by family members were determined to be safety concerns; fewer than 10% of these incidents were felt to be preventable adverse events. Family-reported error rates were similar to error rates drawn from actively eliciting error reports from clinicians. Families were able to identify preventable adverse events that were not detected by any other method. Error rates calculated from hospital incident reports were much lower than those drawn from either clinician or family reports, consistent with prior studies. These results demonstrate that families can identify otherwise undetected adverse events and their input should be elicited in safety surveillance systems.
Auerbach AD, Kripalani S, Vasilevskis EE, et al. JAMA Intern Med. 2016;176:484-93.
… medicine … JAMA Intern Med … Preventing readmissions is a cornerstone of patient safety efforts. However, one concern … care goals , and emergency department decisions to readmit a patient who did not require a second inpatient stay. These results suggest that multiple …
Sokol-Hessner L, White AA, Davis KF, et al. J Hosp Med. 2016;11:245-250.
Although interhospital transfers are considered risky, they are not well characterized. This analysis of inpatient records found that even after adjustment for illness severity and patient characteristics, transferred patients had a higher risk of death compared with patients admitted through the emergency department. This finding should prompt prospective study of transfers to elucidate and address safety vulnerabilities.
Sokol-Hessner L, Folcarelli P, Sands KEF. BMJ Qual Saf. 2015;24:550-3.
… insufficient respect for patients, this commentary reviews a conceptual framework developed by a multidisciplinary panel and recommends that institutions … physical harms. Patient-centered care has been proposed as a strategy for reducing preventable harms. …
White AA, Brock DM, McCotter PI, et al. J Healthc Risk Manag. 2015;34:30-40.
This AHRQ-funded study surveyed risk managers about programs that provide support for clinicians involved in adverse events, who are often referred to as second victims. Approximately three-quarters of organizations reported having a support program, but they varied widely in structure and staffing. Many of the programs lacked elements recommended by national standards, suggesting significant room for improvement.