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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 27 Results
O’Hare AM, Vig EK, Iwashyna TJ, et al. JAMA Netw Open. 2022;5:e2240332.
Long COVID-19 can be challenging to diagnose. Using electronic health record (EHR) data from patients receiving care in the Department of Veterans Affairs, this qualitative study explored the clinical diagnosis and management of long COVID symptoms. Two themes emerged – (1) diagnostic uncertainty about whether symptoms were due to long COVID, particularly given the absence of specific clinical markers and (2) care fragmentation and poor care coordination of post-COVID-19 care processes.
Institute for Safe Medication Practices; 5200 Butler Pike, Plymouth Meeting, PA 19462.
This redesigned Web site provides information about drug safety alerts and allows consumers to help report and prevent medication errors.
Farrell TW, Butler JM, Towsley GL, et al. Int J Environ Res Public Health. 2022;19:5975.
A robust culture of safety encourages open communication between team members. Certified nursing assistants (CNAs) and nurses in nursing homes were asked about the extent to which their input about residents was valued by the other team members. CNAs reported they felt valued by other CNAs and nurses, but less valued by physicians and pharmacists.
Butler AM, Brown DS, Durkin MJ, et al. JAMA Netw Open. 2022;5:e2214153.
Inappropriately prescribing antibiotics for non-bacterial infections remains common in outpatient settings despite the associated risks. This analysis of antibiotics prescribed to more than 2.8 million children showed more than 30% of children with bacterial infection, and 4%-70% of children with viral infection were inappropriately prescribed antibiotics. Inappropriate prescribing led to increased risk of adverse drug events (e.g., allergic reaction) and increased health expenditures in the following 30 days.
Butler CR, Wong SPY, Wightman AG, et al. JAMA Netw Open. 2020;3:e2027315.
The COVID-19 pandemic has led to wide-ranging changes to health care delivery. This qualitative study with clinicians in the United States identified three emerging themes describing clinicians’ experience providing care in settings of resource limitations - planning for crisis capacity, adapting to resource limitations, and unprecedented barriers to care delivery. 
Bhatt AS, Moscone A, McElrath EE, et al. J Am Coll Cardiol. 2020;76:280-288.
Patients are delaying or forgoing necessary care due to concerns about COVID-19 transmission. This study analyzed inpatient discharges between January 2019 and March 2020 at one tertiary healthcare system to explore the trends in hospitalizations for acute cardiovascular conditions (e.g., chest pain, heart failure, stroke) before and during the COVID-19 pandemic. Results showed that during the early months of the pandemic, there was a marked decline in hospitalizations for acute cardiovascular conditions and patients who were admitted had shorter lengths of stay, which may signal that acute care was deferred or abbreviated during the pandemic.
Howlett MM, Butler E, Lavelle KM, et al. Appl Clin Inform. 2020;11.
Using a pre-post approach, this study assessed the impact of implementing electronic prescribing and smart pump-facilitated standard concentration infusions on medication errors in a pediatric intensive care unit (PICU). The overall error rates were similar before and after implementation but the error types changed before and after implementation of these tools. After implementation, lack of clarity, incomplete orders and wrong unit errors were reduced but dosing errors, altered orders and duplicate errors increased. Pre-implementation, 78% of errors were deemed preventable by electronic prescribing and smart-pumps; post-implementation 27% of errors were attributed to the technology and would not have occurred if the order was not electronically created or administered via the smart-pump.
Brown SM, Azoulay E, Benoit D, et al. Am J Respir Crit Care Med. 2018;197:1389-1395.
This commentary explores the results of a multidisciplinary discussion on the intersection of "respect" and "dignity" as requirements of safe care. The authors provide recommendations to encourage a strong system-level commitment to respect and dignity, which include the need to expand the research on respect in the intensive care unit and the value of responding to failures of respect as safety incidents to design mechanisms for improvement.
Janak JC, Sosnov JA, Bares JM, et al. JAMA Surg. 2018;153:367-375.
This systematic review compared military mortality reviews to nonmilitary studies of pre- or in-hospital mortality reviews. The authors note widely varying review processes, data inclusion, and preventability assessment, and recommend standardization of definitions and processes in order to reduce bias.

Michalska-Smith M, ed. AMA J Ethics. 2017;19(8):737-842

… etiology of iatrogenesis in pediatrics . … Michalska-Smith M, ed. AMA J Ethics. 2017;19(8):737-842 … G … N … S … Y … A … … L … S … E … TD … SA … DT … JS … SL … K … TJ … F … N … G … M … R … Allen … Laventhal … Barone … Unguru … Dionigi … Dokumaci … Hock … Karnik … SKassam-Adams … Butler … Reis-Dennis … Reis … Steensma … Wensing-Kruger … …
Fox MD, Bump GM, Butler GA, et al. J Patient Saf. 2021;17:e373-e378.
Medical residents are increasingly exposed to patient safety concepts during their training. This commentary describes the implementation of a longitudinal curriculum to augment resident physicians' error reporting at a pediatric hospital. The project team found the program to be effective in improving the rates of reporting by both residents and other clinicians at the organization.
Bohnen JD, Mavros MN, Ramly EP, et al. Ann Surg. 2017;265:1119-1125.
Intraoperative adverse events have been shown to increase the risk of hospital readmission. In this study, investigators found that intraoperative adverse events during abdominal surgery were associated with increased postoperative mortality, morbidity, and length of stay.

Suresh S, ed. Pediatr Clin North Am. 2016;63:221-388.

Utilizing informatics has shown promise for enhancing quality and patient safety, but this has also introduced unintended consequences. Articles in this special issue explore technology use in pediatric nursing care, including challenges, opportunities, and how to augment utilization of metrics and data for safety improvement.
Butler GA, Hupp DS. Pediatr Clin North Am. 2016;63.
Nurses play a key role in ensuring safety, particularly for pediatric patients. This review highlights the importance of hospital leadership in establishing and sustaining a safety culture that enables nurses to speak up about concerns and describes the benefits of educating nurses in high reliability concepts to augment safety in pediatric practice.
Butler DL, Major Y, Bearman G, et al. The Journal of hospital infection. 2010;75:137-8.
Studies have sought to determine if clinician attire contributes to the transmission of hospital-acquired infections. This newspaper article reports insights from physicians regarding whether white coats can spread germs in the hospital environment.