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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 40 Results
Griffeth EM, Gajic O, Schueler N, et al. J Patient Saf. 2023;19:422-428.
Voluntary reporting is an important tool for institutions to identify latent safety threats before they reach the patient but barriers to reporting result in low reporting rates. This quality improvement (QI) project aimed to increase near miss and error reporting within 9 intensive care units (ICU) in one healthcare system. After identifying barriers to reporting (e.g., user difficulty with online reporting system), a multi-faceted intervention was developed and implemented. Error reporting increased in 6 of 9 ICUs following implementation, with a significant increase in near miss reports.

Gangopadhyaya A, Pugazhendhi A, Austin M et al. Washington DC: Leapfrog Group; 2023.

… than white patients. … Gangopadhyaya A, Pugazhendhi A, Austin M et al. Washington DC: Leapfrog Group; 2023. … Anuj … Avani … … Matt … Alexandra … Missy … Gangopadhyaya … Pugazhendhi … Austin … Campione … Danforth … Anuj Gangopadhyaya … Avani …
Liberman AL, Wang Z, Zhu Y, et al. Diagnosis (Berl). 2023;10:235-241.
Symptom–Disease Pair Analysis of Diagnostic Error (SPADE) is a framework to measure diagnostic errors using existing databases, such as electronic health records or administrative claims. The original developers of the SPADE framework provide additional guidance on types of comparator groups, how to select the appropriate group, and what inferences can be drawn from the analysis.
Auty SG, Barr KD, Frakt AB, et al. Addiction. 2023;118:870-879.
To combat serious adverse events (SAE) and suicide among veterans with opioid use disorder (OUD), the Veterans Health Administration (VHA) implemented the Stratification Tool for Opioid Risk Mitigation (STORM) in all VHA facilities. Patients identified as high-risk for SAE by STORM received a mandatory case review. This study focuses on high-risk patients with a new OUD diagnosis. Mandatory case review increased the odds of all-cause mortality, but not SAE. Patients whose opioids were discontinued after case review showed even higher odds of mortality.
Austin JM, Bane A, Gooder V, et al. J Patient Saf. 2022;18:526-530.
Use of bar code medication administration (BCMA) technology in hospitals has been shown to decrease medication errors at the time of administration. In 2016, the Leapfrog Group implemented a standard for BCMA use as part of its hospital survey. This article describes the development, testing, and subsequent refinement of the BCMA standard.
Iredell B, Mourad H, Nickman NA, et al. Am J Health Syst Pharm. 2022;79:730-735.
The advantages of automation can be safely achieved only when the technologies are implemented into processes that support their proper use in regular and urgent situations. This guideline outlines considerations for the safe use of computerized compounding devices to prepare parenteral nutrition admixtures with the broader application to other IV preparations in mind. Effective policy, training, system variation, and vendor partnerships are elements discussed.
Austin JM, Weeks K, Pronovost PJ. Jt Comm J Qual Patient Saf. 2020;47:265-267.
… Jt Comm J Qual Patient Saf … Prior research has identified racial … diversity among health care workers and leadership.   … Austin JM, Weeks K, Pronovost PJ. Health system leaders' role … to prioritize eliminating health care disparities. Jt Comm J Qual Patient Saf. Epub 2020 Dec 20.     …
Austin J, Barras M, Sullivan C. Int J Med Inform. 2020;135.
The authors systematically reviewed the evidence on electronic health record (EHR) interventions designed to improve the safety and quality of anticoagulation administration in inpatient hospitals settings. The 27 articles meeting inclusion criteria examined four types of interventions: computerized physician order entry (CPOE), clinical decision support systems (CDSS), dashboards, and general EHR implementation. Included studies reported reductions in medication errors and adverse drug events with use of CPOE and CDDS, but studies did not find benefits to other adverse events (e.g., bleeding events), readmissions or length of stay. Overall, the review found limited evidence demonstrating the benefit of inpatient EHR interventions in improving anticoagulation safety and quality.

Int J Qual Health Care. 2020;32(Supp1):1-105.

… impact conditions that affect quality and safety. … Int J Qual Health Care. 2020;32(Supp1):1-105. … G … T … HP … R … … J … F … C … W … E … E … R … O … C … NS … L … SB … Z … A … M … R … P … Arnolda … Winata … Ting … Clay-Williams … Taylor … … Tran … Braithwaite … Saeed … Clay … Hussein … Hogden … Austin … Suñol … Græne … Wagner … Klazinga … Donaldson … …
Lapointe-Shaw L, Bell CM, Austin PC, et al. BMJ Qual Saf. 2020;29:41-51.
Medication reconciliation is an important component of strategies for preventing adverse events after hospital discharge. Studies show that comprehensive medication interventions (including medication reconciliation) by hospital-based pharmacists can reduce adverse events and readmissions in older patients. This Canadian study sought to evaluate whether medication reconciliation and education by community pharmacists could also achieve the same aims for recently discharged patients. This nonrandomized study used propensity score analysis to evaluate outcomes of patients who received medication reconciliation and review of medication adherence performed by community pharmacists during a dedicated visit. Researchers found that patients receiving the service had a reduction in readmissions and death. The magnitude of benefit was small overall, but it was larger in patients who were filling a new prescription for a high-risk medication. Although the nonrandomized design precluded firmer conclusions, this study indicates that community-based medication reconciliation and review may be a promising strategy for reducing adverse events after discharge.

Res Social Adm Pharm. 2019;15(6):780-810.

Appropriate deprescribing can reduce the risks associated with polypharmacy, overuse, and accidental overdose. Articles in this special section cover findings from a symposium discussing guidelines for safe discontinuation of medications and research needed to support further understanding of deprescribing practices.
Sherman J, Hedli LC, Kristensen-Cabrera AI, et al. Am J Perinatol. 2020;37:638-646.
This direct observation study examined maternal and neonatal care at 10 labor and delivery units. Investigators uncovered three environmental needs that impact safety: rapid access to blood products, space for neonatal resuscitation, and organization and availability of equipment and supplies. They conclude that applying design thinking to physical space could improve maternal and neonatal safety.
Ponce BA, Wills BW, Hudson PW, et al. Ann Surg. 2019;269:465-470.
The practice of overlapping surgery has raised significant concerns about patient safety. This retrospective cohort study at a single academic medical center did not find evidence of worse outcomes among patients undergoing overlapping surgery across 13 surgical specialties.
Ravi B, Pincus D, Wasserstein D, et al. JAMA Intern Med. 2018;178:75-83.
Overlapping surgery is the practice of surgeons scheduling distinct procedures on different patients concurrently. This practice has raised safety concerns. This large population-based retrospective study examined outcomes for nonoverlapping versus overlapping hip surgeries across Ontario, Canada. After adjustment for factors known to predict surgical outcomes, such as hospital and surgeon case volume and the patient's overall health, researchers found an association between increasing duration of surgical overlap and higher risk of complications. These results contrast with a recent single-center study that found no safety differences between overlapping and nonoverlapping neurosurgeries. An accompanying editorial acknowledges the mixed results of safety studies for overlapping surgeries and calls for large, multicenter, prospective studies across a range of surgical procedures with long-term follow-up.
Pronovost P, Wu AW, Austin M. JAMA. 2017;318:701-702.
Transparency in the reporting of quality and safety data demonstrates a commitment to improvement, learning, and patient empowerment regarding provider selection. This commentary suggests potential standards for hospitals to adopt for public reporting of their quality data and advocates for an external entity that reports how hospitals adhere to public reporting of quality measures.