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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 36 Results
Prentice JC, Bell SK, Thomas EJ, et al. BMJ Qual Saf. 2020;29:883-894.
… BMJ Qual Saf … This article describes results of a cross-sectional recontact survey of Massachusetts residents … errors. Over half of respondents on the self-reporting a medical error 3-6 years ago survey stated at least one emotional impact, avoiding the doctor(s) or facility(s) involved in the error, and two-thirds of …
Chua K-P, Fischer MA, Linder JA. BMJ. 2019;364:k5092.
Prescribing unnecessary antibiotics increases the risk of resistant infections and can lead to patient harm. In this cross-sectional study, researchers found that 23% of the 15,455,834 outpatient antibiotic prescriptions filled among a cohort of 19.2 million patients over a 1-year period were consistent with inappropriate prescribing.
Seamans MJ, Carey TS, Westreich DJ, et al. JAMA Intern Med. 2018;178:102-109.
… … JAMA Intern Med … Opioids are high-risk medications and a significant source of patient harm . Although prior … else, it remains uncertain whether individuals living in a household with a patient receiving prescription opioids are more likely to …
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.
Schiff G, Nieva HR, Griswold P, et al. Med Care. 2017;55:797-805.
A recent AHRQ technical brief on ambulatory safety found that evidence for effective interventions is lacking. This cluster-randomized controlled trial examined whether participation in a multimodal quality improvement intervention enhanced safety processes at primary care clinics compared to usual practice. Using chart review, investigators determined that clinics receiving the intervention—which included a learning network, webinars, in-person meetings, and coaching—improved documentation and patient notification for abnormal test results overall. Also, time between test date and treatment plan was shorter in intervention sites. Through pre–post surveys, they learned that patient perceptions of quality and safety improved modestly for coordination and communication but were otherwise similar between the sites. Staff perceptions of safety and quality were similar pre–post and between intervention and control sites. Barriers to improvement included time and resource constraints, staff turnover, health information technology, and local practice variation. The authors recommend further study to determine the potential for multimodal practice-level interventions to enhance outpatient safety.
Weingart SN, Weissman JS, Zimmer KP, et al. Int J Qual Health Care. 2017;29:521-526.
… Care … Patient engagement is increasingly recognized as a priority for patient safety efforts. This study team developed and tested a reporting system for patients and families to bring safety … patient safety reporting, not all reports were related to a safety concern. The most common category of mistakes …
Najafzadeh M, Schnipper JL, Shrank WH, et al. Am J Manag Care. 2016;22:654-661.
… medication reconciliation at hospital discharge affects a hospital payer's costs. Investigators calculated that an intervention that … this process at hospital discharge should save costs. A past WebM&M commentary described a medication discrepancy …
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.
Singer SJ, Nieva HR, Brede N, et al. Med Care. 2015;53:141-52.
… and existing safety processes. Administrators reported a lack of safety systems, consistent with prior discussion of … to manage their workload leads to safety problems, echoing a recent focus group study of physicians. Respondents also … opportunities to improve safety in primary care settings. A recent AHRQ WebM&M interview and perspective discuss …
Weissman JS, López L, Schneider EC, et al. Int J Qual Health Care. 2014;26:129-35.
A recent systematic review found that better patient experiences of care are associated with improved patient safety and quality of care. This survey of more than 2500 adults discharged from 16 hospitals in Massachusetts adds to our understanding of this relationship. Patients who self-reported having experienced an adverse event (AE) while hospitalized rated the overall quality of hospital care lower, but this finding was primarily among patients who did not report that the AE they experienced was explicitly disclosed to them. Among patients who experienced an AE, it appeared that patient satisfaction was highest (and nearly equal to satisfaction of patients with error-free hospitalizations) when the error was disclosed, the patients were engaged in their own care, and discharge was perceived as timely. These findings imply that even when patients experience complications, "service recovery" efforts, such as formal error disclosure programs, can positively affect patients' perceptions of the care quality.
Zhu J, Stuver SO, Epstein AM, et al. Med Care. 2011;49:948-55.
Traditional methods of error detection have relied mainly on provider input or administrative data, without emphasizing the role of the patient in safety. This study of more than 2000 patients recently discharged from Massachusetts hospitals found that patients could identify unique adverse effects of hospitalization that may not have been identified by other methods. Importantly, physician reviewers agreed that the patient-reported events constituted a true clinical adverse event in more than 70% of cases. This finding corroborates prior research showing that patient-reported adverse events provide an important complementary perspective in assessing organizational safety problems.
DesRoches CM, Rao SR, Fromson J, et al. JAMA. 2010;304:187-193.
Patient safety initiatives will increasingly balance the tension between systems change and individual accountability, and medical professionalism is often at the center of this discussion. Although certain behaviors in medical school predict unprofessional behavior, efforts to teach these skills have been described, particularly in addressing disruptive behavior. This study surveyed physicians and found that nearly 70% believe that it is their professional responsibility to report an impaired or incompetent colleague. However, of those with knowledge of such a colleague, 33% failed to report them to a relevant authority. Barriers to reporting included a belief that it wasn’t their responsibility, nothing would happen from reporting them, and fear of retribution. A related editorial discusses medical professionalism in the context of this study’s findings and weighs different strategies to address the challenges. A past AHRQ WebM&M conversation and commentary also discuss professionalism and patient safety.
López L, Weissman JS, Schneider EC, et al. Arch Intern Med. 2009;169:1888-94.
… internal medicine … Arch Intern Med … Error disclosure is a practice that was traditionally limited by fears of … its importance to patients. This study analyzed a random sample of medical and surgical hospitalized adults … Dr. Robert Wachter, discusses the importance of this study's findings while reflecting on the 10-year anniversary of the …