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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 54 Results
Woods-Hill CZ, Colantuoni EA, Koontz DW, et al. JAMA Pediatr. 2022;176:690-698.
… tests or antibiotics . This article reports findings from a 14-site multidisciplinary collaborative evaluating … blood culture practices before and after implementation of a diagnostic stewardship intervention. Researchers found that …
Marshall TL, Rinke ML, Olson APJ, et al. Pediatrics. 2022;149:e2020045948D.
… … Reducing diagnostic errors in pediatric care remains a critical area of research and quality improvement. This … interventions to reduce these errors. … Marshall TL, Rinke ML, Olson APJ, et al. Diagnostic error in pediatrics: a narrative review. Pediatrics. 2022;149(Suppl …
Yin HS, Neuspiel DR, Paul IM, et al. Pediatrics. 2021;148:e2021054666.
Children with complex home care needs are vulnerable to medication errors. This guideline suggests strategies to enhance medication safety at home that include focusing on health literacy, prescriber actions, dosing tool appropriateness, communication, and training of caregivers. 
Procaccini D, Kim JM, Lobner K, et al. Jt Comm J Qual Patient Saf. 2022;48:154-164.
… J Qual Patient Saf … Weight-based medication dosing is a common source of medication errors in children. This … clinical significance is unknown. … Procaccini D, Kim JM, Lobner K, et al. Medication errors in overweight and obese pediatric patients: a systematic review. Jt Comm J Qual Patient Saf. Epub 2021 …
Dadlez NM, Adelman JS, Bundy DG, et al. Ped Qual Saf. 2020;5:e299-e305.
Diagnostic errors, including missed diagnoses of adolescent depression, elevated blood pressure, and delayed response to abnormal lab results, are common in pediatric primary care. Building upon previous work, this study used root cause analyses to identify the failure points and contributing factors to these errors. Omitted process steps included failure to screen for adolescent depression, failure to recognize and act on abnormal blood pressure values, and failure to notify families of abnormal lab results. Factors contributing most commonly to these errors were patient volume, inadequate staffing, clinic environment, electronic and written communication, and provider knowledge.
Bundy DG, Singh H, Stein RE, et al. Clin Trials. 2019;16:154-164.
Diagnostic errors in pediatric primary care are common and represent an ongoing patient safety challenge. In this stepped-wedge, cluster-randomized trial, researchers were able to successfully recruit a diverse group of pediatric primary care practices to participate in virtual quality improvement collaboratives designed to reduce diagnostic error.
Modi A, Germain E, Soma V, et al. Jt Comm J Qual Patient Saf. 2018;44:599-604.
Pediatric patients are at particularly high risk for medication errors. This retrospective review of voluntary error reports of pediatric antibiotic errors found that less than 15% reached the patient and 1.5% caused harm. The risk varied by medication class, and authors suggest developing quality improvement initiatives focused on the highest risk medications.
Rinke ML, Singh H, Heo M, et al. Acad Peds. 2018;18:220-227.
In the Improving Diagnosis in Health Care report, the National Academy of Medicine proclaimed that diagnostic errors are common, cause substantial morbidity, and are understudied. This report has led to multidisciplinary efforts to measure diagnostic error rates in both ambulatory and inpatient settings. This study examined the prevalence of three diagnostic errors in pediatric primary care practices. They found that diagnostic errors were common. Providers did not follow up abnormal laboratory values for 11% of patients and did not address adolescent depression in 62% of visits. These high rates are similar to those found in other practice settings. The authors discuss an ongoing quality improvement collaborative working to reduce diagnostic errors in pediatric primary care practices. Previous WebM&M commentaries highlight cognitive and system-level interventions to prevent diagnostic errors.
Rosen MA, Mueller BU, Milstone AM, et al. Jt Comm J Qual Patient Saf. 2017;43:224-231.
… Patient Saf … This commentary describes the development of a multidisciplinary council to collectively lead patient safety efforts for children's hospitals in a large health system. The authors highlight the value the …
Dadlez NM, Azzarone G, Sinnett MJ, et al. Hosp Pediatr. 2017;7:134-139.
Interruptions are known to contribute to medication errors. This direct observation study found that resident physicians and physician assistants experienced 57 interruptions per 100 medication orders. The authors suggest that inpatient health systems should implement strategies to reduce interruptions during medication ordering.
Mathews SC, Demski R, Hooper JE, et al. Acad Med. 2017;92:608-613.
Program infrastructure that incorporates the knowledge of staff at executive and unit levels can enable system improvements to be sustained over time. This commentary describes how an academic medical center integrated departmental needs with overarching organizational concerns to inform safety and quality improvement work. The authors highlight the need for flexibility and structure to ensure success.
Cifra CL, Bembea MM, Fackler JC, et al. Crit Care Med. 2016;17:58-66.
… to learn from medical errors. In this study, introducing a structured systems-oriented morbidity and mortality conference in a pediatric intensive care unit led to higher attendance … interventions. … Cifra CL, Bembea MM, Fackler JC, Miller MR. Transforming the Morbidity and Mortality …
Pronovost P, Demski R, Callender T, et al. Jt Comm J Qual Patient Saf. 2013;39:531-544.
… on accountability measures . The program included creating a robust quality management infrastructure through the … communities, and transparently reporting monthly data with a detailed step-based accountability plan for underachieving … an enduring quality management infrastructure, a project management office, and a formal accountability …
Rinke ML, Bundy DG, Abdullah F, et al. J Patient Saf. 2015;11:123-34.
Some states require public reporting of rates of central line–associated bloodstream infections (CLABSI). Investigators did not find differences in CLABSI rates between states with and without public reporting, suggesting that current transparency efforts are not sufficient to improve this safety target.
Pronovost P, Armstrong M, Demski R, et al. Acad Med. 2015;90:165-172.
… … Acad Med … This study describes the early experience of a new infrastructure for quality and safety at Johns Hopkins Medicine. A major component of this effort was the 2011 creation of the … The new governance structure includes oversight from a patient safety and quality board committee. The overall …
Cifra CL, Bembea MM, Fackler JC, et al. Crit Care Med. 2014;42:2252-7.
Similar to prior research in internal medicine and surgical programs, this survey study found that structure and processes of morbidity and mortality (M&M) conferences in pediatric intensive care units varied widely. Moreover, there was substantial disagreement between respondents, making it unclear whether the M&M conferences actually conform to key elements of medical incident analysis.