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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 61 Results
Huynh J, Alim SA, Chan DC, et al. Ann Intern Med. 2023;176:1448-1455.
Access to primary care is becoming more challenging, in part due to physicians leaving the field. Twenty-nine states have expanded nurse practitioner (NP) autonomy to increase access. This study compares potentially inappropriate prescribing practices between NPs and primary care physicians (PCP). In the study population, adults aged 65 and older, NPs and PCPs had nearly identical rates of potentially inappropriate prescribing. The authors encourage focusing on improving prescribing practices among all prescribers instead of working to limit prescribing to physicians.
Schulz-Moore JS, Bismark M, Jenkinson C, et al. Jt Comm J Qual Patient Saf. 2021;47:376-384.
Error disclosure is critical to improving communication and patient safety. This article describes the development and pilot testing of the Medical Injury Reconciliation Experiences Survey (MIRES). The final 40-item survey addresses patient and/or family perceptions of communications with healthcare providers after the injury, perceptions of remedial gestures, overall satisfaction with the reconciliation process, the nature and impacts of the injury, and patient characteristics.
Mello MM, Frakes MD, Blumenkranz E, et al. JAMA. 2020;323:352-366.
This systematic review synthesized evidence from 37 studies to examine the association between malpractice liability risk and healthcare quality and safety. The review found no evidence of association between liability risk and avoidable hospitalizations or readmissions, and limited evidence supporting an association between risk and mortality (5/20 studies) or patient safety indicators or postoperative complications (2/6 studies).
Sherwood R, Bismark M. BMJ Qual Saf. 2020;29:113-121.
Confidential skill assessments have been recommended as a strategy to ensure competence among aging surgeons. In this qualitative study, the authors describe opinions from 52 experts on how to manage potential concerns associated with aging surgeons.
Moore JS, Mello MM, Bismark M. Bioethics. 2019;33:948-957.
… … Bioethics … Patient engagement is now acknowledged as a cornerstone of patient safety , but the perspectives of … prior studies , researchers found that patients expressed a desire to be heard. Participants had positive perceptions of patient safety research and expressed a desire that others learn from the adverse event they …
Studdert DM, Spittal MJ, Zhang Y, et al. N Engl J Med. 2019;380:1247-1255.
… affected physicians' practice. Investigators found that a small proportion of physicians, about 10%, had one or more … support to remediate their clinical skills and behavior . A PSNet perspective explored the risk of recurring …
Canan C, Polinski JM, Alexander C, et al. J Am Med Inform Assoc. 2017;24:1204-1210.
Safer opioid prescribing requires that providers and systems are able to identify patients who misuse or divert opioids. This systematic review assessed different automated algorithms to detect population-level nonmedical opioid use. The authors suggest that algorithms that integrate claims data with natural language processing or other advanced informatics techniques yield the best results.
Moore J, Bismark M, Mello MM. JAMA Intern Med. 2017;177:1595-1603.
… , but implementing these programs effectively has been a challenge. This study is the first to examine patient … most of whom experienced harm. Respondents expressed a desire for providers to listen to their perspectives … to improve communication-and-resolution programs. A past PSNet interview discussed an organization's pioneering …
Perspective on Safety July 1, 2017
This piece explores the risk of recurring medicolegal events among providers who have received unsolicited patient complaints, faced disciplinary actions by medical boards, or accumulated malpractice claims.
This piece explores the risk of recurring medicolegal events among providers who have received unsolicited patient complaints, faced disciplinary actions by medical boards, or accumulated malpractice claims.
Michelle Mello is Professor of Law at Stanford Law School and Professor of Health Research and Policy at Stanford University School of Medicine. She conducts empirical research into issues at the intersection of law, ethics, and health policy. We spoke with her about legal issues in patient safety.
Najafzadeh M, Schnipper JL, Shrank WH, et al. Am J Manag Care. 2016;22:654-661.
Medication discrepancies between hospital and outpatient regimens can contribute to adverse events following hospital discharge. Pharmacist involvement in medication reconciliation is known to improve medication accuracy and reduce adverse drug events. This modeling study examined how implementing pharmacist-led medication reconciliation at hospital discharge affects a hospital payer's costs. Investigators calculated that an intervention that reduced medication discrepancies by 10% would be cost neutral. If pharmacist-led medication reconciliation improves accuracy as much as prior studies suggest, then implementing this process at hospital discharge should save costs. A past WebM&M commentary described a medication discrepancy that led to an adverse drug event.
WebM&M Case September 1, 2016
Assuming its dosing was similar to morphine, a physician ordered 4 mg of IV hydromorphone for a hospitalized woman with pain from acute pancreatitis. As 1 mg of IV hydromorphone is equivalent to 4 mg of morphine, this represented a large overdose. The patient was soon found unresponsive and apneic—requiring ICU admission, a naloxone infusion overnight, and intubation. While investigating the error, the hospital found other complaints against that particular physician.
Polinski JM, Moore JM, Kyrychenko P, et al. Health Aff (Millwood). 2016;35:1222-9.
This intervention study provided pharmacist support to perform medication reconciliation and care coordination for patients discharged from the hospital. Compared to similar-risk patients who did not receive the intervention, those who had medication reconciliation by pharmacists were less likely to be readmitted to the hospital. These results add to the existing literature supporting the utility of pharmacist-led care transition interventions.
Kachalia A, Mello MM, Nallamothu BK, et al. Circulation. 2016;133:661-71.
This review explores policy and legal approaches to addressing care delivery problems, including strategies that focus on transparency, reimbursement, professional regulation, and tort reform. The authors suggest cardiologists are well-positioned as leaders in adopting these approaches because the conditions they treat are highly visible, common, and expensive.
Studdert DM, Bismark M, Mello MM, et al. New Engl J Med. 2016;374:354-362.
A growing body of research has begun to assess the role of individual clinicians in patient safety, seeking to identify clinicians whose patients are at elevated risk of adverse events. Examining data on paid malpractice claims from the National Practitioner Data Bank over a 10-year period, this study found that 1% of physicians accounted for 32% of paid claims. Moreover, recidivism was common, in that practitioners with more than 3 claims had a 24% risk of another claim within the next 2 years. As in prior studies of malpractice data, surgeons and obstetricians were more likely to have paid a claim than internists. The pattern of a relatively small number of physicians incurring repeated claims, which mirrors data from studies of patient complaints, implies that it may be possible to identify clinicians who are at high risk of subsequent malpractice claims or patient complaints. The issues around such high-risk physicians are discussed in a previous WebM&M perspective.
Spittal MJ, Bismark M, Studdert DM. BMJ Qual Saf. 2015;24:360-8.
… quality & safety … BMJ Qual Saf … Past studies have found a correlation between patient complaints and patient safety … sought to identify physicians at highest risk for a second patient complaint using routinely collected administrative data. They developed a risk prediction model which predicted future complaints …
Mello MM, Studdert DM, Kachalia A. JAMA. 2014;312:2146-55.
… explores the current environment, in which there has been a declining rate of paid claims as well as decreasing or flat … process rather than usual courts) will all play a larger role and lead to more rapid resolution following … which would permit providers to use adherence to a clinical guideline as a defense. Formation of accountable …
Bismark M, Studdert DM. BMJ Qual Saf. 2014;23:474-82.
This qualitative study found that most health care leaders believe that board members have opportunities to influence quality and safety. However, insufficient knowledge, experience, and performance measurement may hinder board engagement in quality and safety, and these barriers may contribute to deficiencies in performance.
Wu AW, McCay L, Levinson W, et al. J Patient Saf. 2017;13:43-49.
… Journal of patient safety … J Patient Saf … Based on a series of international expert meetings, this qualitative … enhanced patient and provider education to foster a blame-free safety culture , and establishment of standard … disclosure across institutions. In a past AHRQ WebM&M perspective , Dr. Albert Wu discussed the importance of …