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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 - 14 of 14 Results
Elder NC. BMJ Qual Saf. 2015;24:667-70.
Insufficient communication of laboratory test results can contribute to delays in diagnosis. Discussing poor communication regarding test results in primary care, this commentary advocates for research to understand the best ways to notify patients about their results and involve patients in shared decision-making so that they understand the physician's interpretation and recommendations.
Crane S, Sloane PD, Elder NC, et al. J Am Board Fam Med. 2015;28:452-60.
This study describes the successful implementation of a Web-based reporting system for near-miss events in primary care practices. The most prevalent reports were breakdowns in office processes, with varying risk for adverse events, as found in prior studies of incident reporting. Although near-miss reporting can stimulate improvement efforts, it is not a precise method for detecting safety problems.
Smucker DR, Regan S, Elder NC, et al. J Palliat Med. 2014;17:540-4.
Examining patient safety in home hospice care, the authors found that falls and inadequate symptom control (an error of omission) were the most common concerns, often related to patient or family caregiver actions rather than the home hospice team. This study reveals unique safety considerations around providing end-of-life care for patients.
Elder NC, McEwen TR, Flach J, et al. Fam Med. 2010;42:327-33.
Electronic health records (EHRs) hold great promise for improving patient safety, but remain underutilized, especially in ambulatory care settings. Failure to appropriately follow up on abnormal test results is a common ambulatory care safety problem, and has been implicated in malpractice lawsuits arising from missed or delayed diagnoses. In this study conducted at eight family medicine clinics, those with an EHR documented clinician and patient notification of abnormal test results and clear follow-up plans more often than those with paper charts. However, even in clinics using EHRs, more than one-third of abnormal results had no follow-up plan documented. This finding corroborates prior research that clinician notification alone does not ensure timely and complete follow-up of test results.
Elder NC, Brungs SM, Nagy M, et al. J Patient Saf. 2008;4.
Developing and promoting incident reporting systems is essential to ensuring a culture of safety. However, many barriers—real and perceived—prevent frontline clinicians from reporting errors. This study compared nurses' responses during focus groups to institutional safety culture measurements, and found that although nurses reported adequate access to reporting systems, few actually reported errors, for both practical and cultural reasons. An AHRQ WebM&M commentary discusses a case where a nurse was discouraged from reporting a medication error.
Elder NC, Regan SL, Pallerla H, et al. J Patient Saf. 2008;4.
This study describes the impact of a pilot intervention focused on educating and improving the capacity of elderly patients to communicate with their health care providers. The authors found that the time-intensive effort can improve patients' self-reported behaviors and their safety knowledge.
Elder NC, Graham D, Brandt E, et al. J Am Board Fam Med. 2007;20:115-23.
While incident reporting is an accepted method of error detection in the inpatient setting, it remains underutilized in ambulatory practice. In this survey, researchers conducted focus groups with physicians, nurses, and office staff around the issue of error reporting. Respondents reported that logistical factors were the major barrier to reporting errors, principally the additional effort required to report an error and lack of clear guidelines on which errors should be reported and how much information should be provided. A prior study found similar concerns among inpatient-based providers.
Phillips RL, Dovey SM, Graham D, et al. J Patient Saf. 2008;2.
This AHRQ–funded study discovered differential reporting patterns among staff, clinicians, and patients in 10 family medicine clinics. Using anonymous reporting systems during a defined study period, investigators analyzed more than 900 errors generated by an even distribution of reports from staff and clinicians. However, while staff focused on errors in patient flow and communication, clinicians noted mostly medication- and laboratory-related errors. Overall, the large majority of errors were classified as process errors rather than as knowledge- and skill-related errors. Very few patient-generated reports described an error, suggesting that different strategies may be required to engage patients in similar reporting efforts.
Perspective on Safety May 1, 2006
Dr. Jones was sure he had increased Mr. H's cholesterol-lowering medication to 80 mg 6 months ago, but, at his visit today, his pill bottle still says 40 mg. In reviewing Ms. B's chart in preparation for performing a well-woman examination, Dr. Smith find...
Dr. Jones was sure he had increased Mr. H's cholesterol-lowering medication to 80 mg 6 months ago, but, at his visit today, his pill bottle still says 40 mg. In reviewing Ms. B's chart in preparation for performing a well-woman examination, Dr. Smith find...