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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
Barnett ML, Meara E, Lewinson T, et al. New Engl J Med. 2023;388:1779-1789.
Best practices for treating patients with opioid use disorder (OUD) include prescribing medications to treat OUD (naltrexone, naloxone, or buprenorphine) and limiting prescriptions of high-risk medications (opioid analgesics and benzodiazepines). This study of more than 23,000 patients with an index event related to OUD sought to determine racial and ethnic differences in safe prescribing. White patients were significantly more likely to receive buprenorphine and less likely to receive high-risk medications than Black or Hispanic patients in the 180 days after the index event. This difference persisted over the four-year study period.
Varady NH, Worsham CM, Chen AF, et al. Proc Natl Acad Sci USA. 2022;119:e2210226119.
Safe prescribing dictates that prescriptions should only be written for the patients who are intended to use the prescribed medications. Using claims data, this analysis identified a high rate of opioid prescriptions written for and filled by the spouses of patients undergoing outpatient surgery (who may be unable to fill prescriptions themselves after surgery). Findings suggest intentional, clinically inappropriate prescribing of opioids.
Sun EC, Mello MM, Vaughn MT, et al. JAMA Intern Med. 2022;182:720-728.
Physician fatigue can inhibit decision-making and contribute to poor performance. This cross-sectional study examined surgical procedures performed between January 2010 and August 2020 across 20 high-volume hospitals in the United States to determine the association between surgeon fatigue, operating overnight and outcomes for operations performed by the same surgeon the next day. No significant associations were found between overnight surgeries and surgical outcomes for procedures performed the next day.
Neprash HT, Sheridan B, Jena AB, et al. Health Aff (Millwood). 2021;40:1321-1327.
The COVID-19 pandemic led to an increase in the use of telehealth in order to limit patient exposure to the virus. Findings from this study highlight the value of telehealth visits for patients with suspected respiratory infections to prevent further transmission. Researchers found that patients exposed to influenza-like illness in primary care office settings were more likely than nonexposed patients to return with a similar illness within two weeks.
Worsham CM, Woo J, Jena AB, et al. Health Aff (Millwood). 2021;40:970-978.
Adolescent patients transitioning from pediatric to adult medicine may experience patient safety risks. Using a large commercial insurance claims database, the authors compared opioid prescribing patterns and risk for opioid-related adverse events (overdose, opioid use disorder, or long-term use) among adolescents transitioning from “child” to “adult” at 18 years of age. The authors estimate a 14% increased risk for an opioid-related adverse outcome within one year when “adults” just over age 18 years were prescribed opioids that would not have been prescribed if they were under 18 years and considered “children.” The authors discuss how systematic differences in how pediatric and adult patients may be treated can lead to differences in opioid prescribing.
McGarry BE, Grabowski DC, Barnett ML. Health Aff (Milwood). 2020;39:1812-1821.
Based on data from the CMS COVID-19 Nursing Home Database, this study found that more than 20% of nursing homes report a severe shortage of personal protective equipment (PPE) and shortage of staff; rates for staffing and PPE did not improve from May to July of 2020. Nursing homes with COVID-19 cases among residents and staff, and those with lower quality scores, were more likely to report shortages.
Neprash HT, Barnett ML. JAMA Netw Open. 2019;2:e1910373.
The root causes of the opioid epidemic are complex, but inappropriate prescribing of opioids (which includes both prescribing opioids in situations where they are not indicated as well as excessive prescribing for appropriate indications) is a major contributor. Prior studies of outpatient antibiotic prescribing have shown that rates of inappropriate prescribing rise toward the end of clinicians' clinic sessions. This cross-sectional study used data from 5603 primary care physicians for acute painful conditions to analyze whether a similar relationship exists for opioid prescribing. Investigators found that the likelihood of opioid prescribing rose considerably as the workday progressed; clinicians were also more likely to prescribe opioids if their appointments were running late. In contrast, prescriptions for nonopioid therapies did not change in relation to appointment time. Although the magnitude of these effects was smaller than the variation in opioid prescribing rates between physicians found in other studies, these findings confirm that production pressure and decision fatigue contribute to inappropriate prescribing and should be addressed in quality improvement efforts to reduce opioid use.
Jena AB, Farid M, Blumenthal D, et al. BMJ. 2019;366:l4134.
In 2003, the Accreditation Council for Graduate Medical Education limited resident physician work hours to 30 hours in 1 shift and 80 hours in 1 week. These duty hour reforms were intended to enhance patient safety and trainee physician well-being. However, some have expressed concern that physicians who train for fewer hours will leave residency less skilled and ultimately provide lower quality care. Investigators assessed whether attending internists who trained with duty hour restrictions differed after residency in terms of their Medicare patients' mortality, readmissions, or costs when compared with internists who trained with unlimited duty hours. They found no difference in quality or cost between the two physician groups. Although other studies have concluded that duty hours have not adversely affected clinical or safety outcomes in residency, this study extends that finding to physicians' subsequent practice. Duty hour restrictions have consistently been associated with improved resident physician well-being. A PSNet perspective reviewed changes to the ACGME requirements to create flexibility for work hours within the maximum 80-hour workweek.
Barnett ML, Boddupalli D, Nundy S, et al. JAMA Netw Open. 2019;2:e190096.
Timely and accurate diagnosis is a prerequisite for safe and high-quality treatment. This study used data from the Human Diagnosis Project (Human Dx, an online case-solving platform) to examine diagnostic accuracy among individual physicians compared to groups of physicians (collective intelligence). Physicians can enter cases onto the platform or solve cases that others have entered. The more physicians involved in solving a given case, the more likely that the correct diagnosis would be identified. Groups of physicians across specialties outperformed individual subspecialists even for subspecialty-relevant cases. The authors advocate for testing the use of collective intelligence for diagnosis in clinical settings. A related editorial discusses how teaching diagnosis has evolved and the possibility of using collective intelligence to improve diagnostic accuracy. In a previous PSNet interview, Shantanu Nundy, Director of Human Dx, discussed his work with the project.
Sun E, Mello MM, Rishel CA, et al. JAMA. 2019;321:762-772.
Scheduling overlapping surgeries has raised substantial patient safety concerns. However, research regarding the impact of concurrent surgery on patient outcomes has produced conflicting results. In this multicenter retrospective cohort study, researchers examined the relationship between overlapping surgery and mortality, postoperative complications, and surgery duration for 66,430 surgeries between January 2010 and May 2018. Although overlapping surgery was not significantly associated with an increase in mortality or complications overall, researchers did find a significant association between overlapping surgery and increased length of surgery. An accompanying editorial discusses the role of overlapping surgery in promoting the autonomy of those in surgical training and suggests that further research is needed to settle the debate regarding the impact of overlapping surgery on patient safety.
Carey CM, Jena AB, Barnett ML. Ann Intern Med. 2018;168:837-845.
This study used Medicare data to examine the relationship between potential opioid misuse and opioid overdose. Researchers defined six possible indicators of opioid misuse (e.g., obtaining opioids from more than five prescribers or more than five pharmacies) in a manner conceptually similar to trigger tools. Patients with any of these opioid use triggers were significantly more likely to experience an overdose within the next 6 months. These results provide insight on how best to use data from prescription drug monitoring programs, which are now widely used as a tool in combating the opioid epidemic.
Blumenthal DM, Olenski AR, Tsugawa Y, et al. JAMA. 2017;318.
This study examined whether receiving care from locum tenens (short-term substitute) physicians in hospital internal medicine practice affects patient outcomes. The concern is that discontinuity might increase risk for adverse events. This retrospective observational cohort study of Medicare patients found no differences in 30-day mortality in those treated by locum tenens physicians compared to those who were not exposed to any substitute physicians. While costs and length of stay were higher for patients with substitute physicians, readmission rates were lower. The authors conclude that locum tenens physicians do not adversely affect safety outcomes like mortality.
Barnett ML, Gray J, Zink A, et al. New Engl J Med. 2017;377:2306-2309.
Policy solutions are one approach to help change prescribing and use patterns that have contributed to the opioid epidemic. This commentary describes how a state-level program sought to reduce opioid misuse and highlights the need for effective monitoring to drive policy-focused improvement initiatives.
Schaffer A, Jena AB, Seabury SA, et al. JAMA Intern Med. 2017;177:710-718.
This retrospective study of a claims database found that medical malpractice claims declined significantly between 1992 and 2014, but mean payment amounts increased at the same time. Diagnostic error was the overall most common reason for a claim, affirming the importance of improving diagnosis.
Barnett ML, Olenski AR, Jena AB. JAMA Intern Med. 2017;177:693-700.
Prior research has demonstrated that hospital accreditation by The Joint Commission is associated with improved hospital performance on certain quality of care measures. However, it has not been established whether the survey periods themselves are associated with a change in patient outcomes. Researchers analyzed Medicare admissions at 1984 hospitals surveyed by The Joint Commission between 2008 and 2012 from 3 weeks prior to a survey up to 3 weeks afterward. They compared patient outcomes between survey periods and the surrounding weeks. For the primary outcome—30-day mortality—patients admitted to the hospital during survey periods had significantly lower mortality than those admitted during nonsurvey weeks, suggesting that heightened vigilance during survey weeks and resultant changes in practice may explain this finding. This interpretation captured much attention and calls for making heightened vigilance a year-round phenomenon. The study reported detectable reductions in mortality at the outset of survey weeks and reversion to previsit levels when survey weeks end. A past PSNet interview with the president of The Joint Commission discussed his role in the organization.
Barnett ML, Olenski AR, Jena AB. N Engl J Med. 2017;376:663-673.
The opioid epidemic is currently one of the most pressing patient safety challenges, as discussed in a recent Annual Perspective. High-risk prescribing practices by clinicians is one contributing factor in the surge in opioid use among patients. Prior research has shown that patients often receive opioids following low-risk procedures, and they frequently receive opioid prescriptions even after overdosing on these medications. This cohort study found wide variations in opioid prescribing practices among emergency departments, with some physicians prescribing opioids almost three times as often even after controlling for patient characteristics. Notably, patients who received opioids from a high-intensity prescriber were significantly more likely to continue using opioids 12 months later—indicating a possible connection between physician prescribing practices and subsequent opioid addiction. The study confirms that reducing variation in physician prescribing practices should be one component of an overall strategy to address opioid overuse.
Obermeyer Z, Cohn B, Wilson M, et al. BMJ. 2017;356:j239.
The emergency department is considered a high-risk setting for diagnostic errors. This analysis of Medicare claims data found that a significant number of adults age 65–89 died within a week of visiting and being discharged from an emergency department, even when no life-limiting illness was noted. Hospitals that admit a lower proportion of emergency department patients to the inpatient setting had a higher mortality rate among discharged patients, even after adjusting for patient characteristics. Consistent with prior studies relating patient outcomes to volume, higher-volume emergency departments had lower 7-day mortality among discharged patients. These results suggest that emergency department discharges may represent missed diagnoses. A WebM&M commentary discussed an incident involving a patient who died after being discharged from the emergency department.
Jena AB, Goldman D, Karaca-Mandic P. JAMA Intern Med. 2016;176:990-7.
Misuse of prescription opioids represents a serious patient safety issue. In this study, investigators examined opioid prescribing to Medicare beneficiaries upon hospital discharge. They found that new opioid use was common after discharge and that prescribing rates varied widely across hospitals.
Semigran HL, Levine DM, Nundy S, et al. JAMA Intern Med. 2016;176:1860-1861.
Information technology approaches have been advocated as a means of preventing diagnostic error. This study compared the diagnostic accuracy of computerized symptom checkers (software programs that use diagnostic algorithms based on patients' self-reported symptoms to suggest diagnoses) with that of practicing physicians. Physicians consistently arrived at more accurate diagnoses across a variety of simulated cases.
Barnett ML, Mehrotra A, Jena AB. BMJ. 2016;354:i3835.
Electronic health records (EHRs) offer safety benefits, but the disruption associated with EHR implementation can lead to unintended consequences as well. This observational study sought to determine whether the incidence of adverse patient outcomes (including certain AHRQ Patient Safety Indicators, readmissions, and mortality) was higher at 17 hospitals that were transitioning to a new EHR than in 399 hospitals that did not change their EHR. Investigators found no significant difference between safety outcomes of hospitals with a new EHR and those without a new EHR. This large-scale study across multiple institutions demonstrates that patients' care remains safe during EHR transitions. The authors suggest that these results should allay safety concerns for institutions planning to implement EHRs. A PSNet interview described the challenges associated with EHR transitions.