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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 114 Results
Williams SR, Sebok-Syer SS, Caretta-Weyer H, et al. BMC Med Educ. 2023;23:434.
Standardizing handoff training in residency programs can lead to safer, more effective handoffs. Researchers surveyed a sample of 687 residents and fellows from over 30 specialties about handoff training perspectives. Participants reported wide variability in handoff content and identified important aspects of handoff training (critical handoff elements, the impact of systems-level factors, impact of the handoff on providers and patients, professional duty, and addressing blame or guilt related to poor handoff experiences).
Yang CJ, Saggar V, Seneviratne N, et al. Jt Comm J Qual Patient Saf. 2023;49:297-305.
Simulation training is commonly used by hospitals to identify threats to safety and improve patient care. This article describes the development and implementation of an in situ simulation to improve acute airway management during the COVID-19 pandemic across five emergency departments. The simulation protocol helped identify latent safety threats involving equipment, infection control, and communication. The simulation process also helped staff identify interventions to reduce latent safety threats, including improved accessibility of airway management equipment, a designated infection control cart, and role identification cards to improve team function.
Schnipper JL, Reyes Nieva H, Yoon CS, et al. BMJ Qual Saf. 2023;32:457-469.
Implementing successful interventions to support effective medication reconciliation is an ongoing challenge. The MARQUIS2 study examined whether system- and patient-level interventions plus physician mentors can improve medication reconciliation and reduce medication discrepancies. This analysis based on patient exposure in the MARQUIS2 study found that patient receipt of a best possible medication history (BPMH) in the emergency department and medication reconciliation at admission and discharge were associated with the largest reductions in medication discrepancy rates.
Malik MA, Motta-Calderon D, Piniella N, et al. Diagnosis (Berl). 2022;9:446-457.
Structured tools are increasingly used to identify diagnostic errors and related harms using electronic health record data. In this study, researchers compared the performance of two validated tools (Safer Dx and the DEER taxonomy) to identify diagnostic errors among patients with preventable or non-preventable deaths. Findings indicate that diagnostic errors and diagnostic process failures contributing to death were higher in preventable deaths (56%) but were also present in non-preventable deaths (17%).
Samal L, Khasnabish S, Foskett C, et al. J Patient Saf. 2022;18:611-616.
Adverse events can be identified through multiple methods, including trigger tools and voluntary reporting systems. In this comparison study, the Global Trigger Tool identified 79 AE in 88 oncology patients, compared to 21 in the voluntary reporting system; only two AE were identified by both. Results indicate multiple sources should be used to detect AE.
WebM&M Case April 27, 2022
… Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council for … [ Available at ] Torres F, Galán MD, Alonso Mdel M, Suárez R, Camacho C, Almagro V. Intraosseous access EZ-IO in a … 1991;58(3):329–34. [ Available at ] Waisman M, Waisman D. Bone marrow infusion in adults. J Trauma . …
Dekhtyar M, Park YS, Kalinyak J, et al. Diagnosis (Berl). 2022;9:69-76.
Standardized and virtual patient encounters are often used to develop medical and nursing students’ diagnostic reasoning. Through educational interventions including virtual patients, medical students increased their diagnostic accuracy compared to baseline and the completeness and efficiency in the differential diagnosis increased.
Kwok CS, Bennett S, Azam Z, et al. Crit Pathw Cardiol. 2021;20:155-162.
Misdiagnosis of cardiovascular conditions can lead to serious patient harm. This systematic review found that misdiagnosis of acute myocardial infarction (AMI) occurs in approximately 1-2% of cases, and AMI is commonly diagnosed as other heart conditions, musculoskeletal pain, or gastrointestinal disease. The authors suggest that there are opportunities to reduce cases of missed AMI with better education about atypical symptoms and improved training of electrocardiogram interpretation.
WebM&M Case September 29, 2021
… Disclosure of Relevant Financial Relationships: … As a provider accredited by the Accreditation Council for … Clin Infect Dis 1987;9(2):265–74. Sampath P, Rigamonti D. Spinal Epidural Abscess. J Spinal Disord 1999;12(2):89–93. … Engl J Medicine 2006;355(19):2012–20. DiGiorgio AM, Stein R, Morrow KD, et al. The increasing frequency of intravenous …
Schnipper JL, Reyes Nieva H, Mallouk M, et al. BMJ Qual Saf. 2022;31:278-286.
… pragmatic quality improvement study (MARQUIS2) implemented a refined toolkit including system-level and patient-level … 17 hospital sites, the intervention was associated with a significant decrease in unintentional mediation … Schnipper JL, Reyes Nieva H, Mallouk M, et al. Effects of a refined evidence-based toolkit and mentored implementation …
Hong K, Hong YD, Cooke CE. Res Social Adm Pharm. 2019;15:823-826.
Medication errors are common in inpatient and ambulatory environments. This commentary summarizes the research exploring the current status of medication safety incident reporting and reduction efforts in community pharmacies. The authors call for community pharmacy corporations to encourage the discussion and data sharing needed to increase transparency around incidents in this care setting. A recent PSNet interview discussed challenges to safety in the retail pharmacy environment.
Khan A, Spector ND, Baird JD, et al. BMJ. 2018;363:k4764.
Patient engagement in safety takes many forms: patients may report unique safety incidents, encourage adherence to best medical practice, and coproduce improvement initiatives. Family-centered rounding in pediatrics invites families to express concerns, clarify information, and provide real-time input to the health care team. This pre–post study explored the safety impact of Patient and Family Centered (PFC) I-PASS rounds on 3106 admissions in pediatric units at 7 hospitals. Family-centered rounds reduced both preventable and nonpreventable adverse events. They also improved family experience without substantially lengthening rounding time. A past PSNet interview discussed the safety benefits of structured communication between health care providers and family members.
Schnock KO, Dykes PC, Albert J, et al. Drug Saf. 2018;41:591-602.
… Researchers describe the development and implementation of a multicomponent safety intervention bundle developed to … decreased, the intervention did not lead to a reduction in the rate of potentially harmful errors. A past PSNet perspective discussed the use of smart pumps to …
Dalal A, Schaffer A, Gershanik EF, et al. J Gen Intern Med. 2018;33:1043-1051.
… follow-up of tests pending at hospital discharge is a persistent patient safety issue. This cluster-randomized … that automated clinician notification does not constitute a sufficient intervention to optimize management of tests …
Boockvar K, Ho W, Pruskowski J, et al. J Am Med Inform Assoc. 2017;24:1095-1101.
Inaccurate medication reconciliation leads to medication discrepancies and places patients at risk for adverse drug events. Health information exchange can enhance medication safety through improved access to prescribing information. In this cluster-randomized trial, a pharmacist performed medication reconciliation with access to a regional health information exchange for patients admitted to a single hospital in the intervention arm and without such information access for patients in the control arm. In the first 10 months of the study, the health information exchange provided access to prescribing information from large hospitals and a pharmacy insurance plan, but only hospital prescribing information was available during the last 21 months because the insurance plan began charging for data. Although researchers found no significant difference between the intervention and control groups with regard to the number of medication discrepancies, patients who underwent medication reconciliation with access to pharmacy insurance data had a higher number of medication discrepancies identified than control patients. They conclude that charging for pharmacy data interrupted the positive effect of health information exchange on medication reconciliation in the study. A past WebM&M commentary described how lack of access to prescribing information led to an adverse drug event.
Lee J, Park SW, Kim YS, et al. Medicine (Baltimore). 2017;96:e7468.
Failure to detect abnormalities during testing can lead to missed or delayed diagnoses. In this retrospective observational study, investigators found that nearly 20% of colonoscopies that needed to be repeated within 6 months had an undetected abnormal finding—a polyp—that was not initially detected. The authors caution that there is significant risk of missing abnormal findings on colonoscopy.