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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
Cifra CL, Custer JW, Smith CM, et al. Crit Care Med. 2023;51:1492-1501.
Diagnostic errors remain a major healthcare concern. This study was a retrospective record review of 882 pediatric intensive care unit (PICU) patients to identify diagnostic errors using the Revised Safer Dx tool. Diagnostic errors were found in 13 (1.5%) patients, most commonly associated with atypical presentation and diagnostic uncertainty at admission.
Braun B, Chitavi SO, Perkins KM, et al. Jt Comm J Qual Patient Saf. 2020;46:531-541.
In this retrospective review of ambulatory care infection prevention and control (IPC) breaches reported to state health departments, the authors observed 5% rate of breaches and found that common breaches involved sterilization and disinfection of reusable devices, device reprocessing, and IPC infrastructure. These and other breaches highlight opportunities for additional training, leadership oversight, and resource investment.
Hedlund N, Beer I, Hoppe-Tichy T, et al. BMJ Open. 2017;7:e015912.
Errors in medication preparation and administration can lead to patient harm. Examining the evidence on intravenous preparation errors in hospitals, this systematic review suggests that there is significant opportunity to improve the intravenous medication preparation process.
Genco EK, Forster JE, Flaten H, et al. Ann Emerg Med. 2016;67:240-248.e3.
The concept of "number needed to treat" is used to quantify the number of patients who would need to undergo therapy to prevent one adverse clinical outcome. This study of opioid prescribing in an academic emergency department found that prescribers had to view more than 123 unnecessary alerts to prevent one adverse drug event. Studies such as this help quantify the number needed to treat for computerized warnings, a critical step forward in understanding and mitigating alert fatigue.
Lohmann K, Gartner D, Kurze R, et al. J Clin Pharm Ther. 2015;40:220-225.
Crushing pills or capsules is sometimes necessary when a patient is not capable of swallowing normally, but this can also be a source of medication errors. This study, conducted in a university hospital in Germany, demonstrated a significant reduction in inappropriate crushing of medications after an intensive educational program.