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 97 Results

Why admitting to mistakes can help doctors (and patients).

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McDonald T. TEDxSanDiego. September 23, 2023.

The lack of a safety culture fundamentally restricts the ability of clinicians to address mistakes, psychologically deal with them and learn. The CANDOR system is highlighted in this presentation by one of the originators of the concept as a strategy for successful resolution, learning and support for those involved in medical error.

"It's probably an STI because you're gay": a qualitative study of diagnostic error experiences in sexual and gender minority individuals.

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Wiegand AA, Sheikh T, Zannath F, et al. BMJ Qual Saf. 2023;Epub May 10.

Sexual and gender minority (SGM) patients may experience poor quality of healthcare due to stigma and discrimination. This qualitative study explored diagnostic challenges and the impact of diagnostic errors among 20 participants identifying as sexual minorities and/or gender minorities. Participants attribute diagnostic error to provider-level and personal challenges and how diagnostic error worsened health outcomes and led to disengagement from healthcare. The authors of this article also summarize patient-proposed solutions to diagnostic error through the use of inclusive language, increasing education and training on SGM topics, and inclusion of more SGM individuals in healthcare.

Using consumer engagement strategies to improve healthcare safety for young people: an exploration of the relevance and suitability of current approaches.

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Newman B, Joseph K, McDonald FEJ, et al. Health Expect. 2022;25:3215-3224.

Patient engagement focuses on involving patients in detecting adverse events, empowering patients to speak up, and emphasizing the patient’s role in a culture of safety. Young people ages 16-25 with experiences in cancer care, and staff who support young people with cancer were asked about their experiences with three types of patient engagement strategies. Four themes for engaging young people emerged, including empowerment, transparency, participatory culture, and flexibility. Across all these was a fifth theme of transition from youth to adult care.

Human centered design workshops as a meta-solution to diagnostic disparities.

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Wiegand AA, Dukhanin V, Sheikh T, et al. Diagnosis (Berl). 2022;9:458-467.

Previous research has identified gender and racial disparities in the burden of diagnostic errors. In this study, researchers conducted a series of human-centered design workshops with a diverse set of stakeholders who generated a set of design challenges, principles, and solutions for addressing diagnostic disparities, improving healthcare quality, and promoting equity and inclusion of marginalized patients. Participants also identified two prototypes for the solutions – a visit preparation guide to teach patients how to advocate for themselves and a tool for identifying patients who may be at increased risk for experiencing a diagnostic error.

Diagnostic Excellence.

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JAMA. Nov 2021-Sep 2022.

Diagnostic excellence achievement is becoming a primary focus in health care. This 20 article series covers diagnosis as it relates to the Institute of Medicine quality domains, clinical challenges, and priorities for improvement across the system.

The MedSafer study-electronic decision support for deprescribing in hospitalized older adults: a cluster randomized clinical trial.

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McDonald EG, Wu PE, Rashidi B, et al. JAMA Intern Med. 2022;182:265-273.

… adverse drug events or adverse drug withdrawal events. … McDonald EG, Wu PE, Rashidi B, et al. The MedSafer …

Incorporating harms into the weighting of the Revised AHRQ Patient Safety for Selected Indicators Composite (PSI 90).

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Zrelak PA, Utter GH, McDonald KM, et al. Health Serv Res. 2022;57:654-667.

The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) are widely used for measuring and reporting hospital quality and patient safety. This paper describes the process of reweighing the composite patient safety indicator (PSI 90) to incorporate excess harm reflecting patients’ preferences for various possible related outcomes (e.g., readmissions, reoperation, long-term care stay, death). Compared to the original frequency-based weighting, some component indicators in the reweighted composite – including postoperative respiratory failure, postoperative sepsis, and perioperative pulmonary embolism or deep vein thrombosis – contributed to the greatest harm.

Improving self-reported empathy and communication skills through harm in healthcare response training.

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Samuels A, Broome ME, McDonald TB, et al. J Patient Saf Risk Manage. 2021;26:251-260.

Healthcare systems have implemented communication-and-resolution programs (CRPs) (aka CANDOR) to encourage early disclosure of adverse events. This evaluation found that CRP training participants demonstrated improvements in self-reported empathy and communication skills.

Crossing academic boundaries for diagnostic safety: 10 complex challenges and potential solutions from clinical perspectives and high-reliability organizing principles.

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Yousef EA, Sutcliffe KM, McDonald KM, et al. Hum Factors. 2022;64:6-20.

… and improve patient outcomes. … Yousef EA, Sutcliffe KM, McDonald KM, et al. Crossing academic boundaries for …

Implementing, Studying, and Reporting Health System Improvement in the Era of Electronic Health Records.

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Auerbach AD, Bates DW, Rao JK, et al, eds. Ann Intern Med. 2020;172(11_Supp):S69-S144.

Research and error reporting are important strategies to uncover problems in health system performance. This special issue highlights vendor transparency and context as important areas of focus to ensure electronic health records (EHR) research and reporting help improve system reliability. The articles cover topics such as a framework for research reporting, design of randomized controlled trials for technology studies, and designing research on patient portal enhancement.

The MedSafer Study: a controlled trial of an electronic decision support tool for deprescribing in acute care.

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McDonald EG, Wu PE, Rashidi B, et al. J Am Geriatr Soc. 2019;67:1843-1850.

This pre–post study compared patients who received medication reconciliation that was usual care at the time of hospital discharge to patients in the intervention arm who had decision support for deprescribing. Although the intervention did lead to more discontinuation of potentially inappropriate medications, there was no difference in adverse drug events between groups. The authors suggest larger studies to elucidate the potential to address medication safety using deprescribing decision support.

Type 1 diabetes defined by severe insulin deficiency occurs after 30 years of age and is commonly treated as type 2 diabetes.

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Thomas NJ, Lynam AL, Hill A, et al. Diabetologia. 2019;62:1167-1172.

This population-based cohort study sought to determine whether patients with adult-onset type 1 diabetes are misdiagnosed. Investigators found that 21% of the patients diagnosed with type 2 diabetes after age 30 actually had type 1 diabetes. They caution clinicians to carefully consider type 1 diabetes in adults requiring insulin.

A qualitative analysis of outpatient medication use in community settings: observed safety vulnerabilities and recommendations for improved patient safety.

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Lyson HC, Sharma AE, Cherian R, et al. J Patient Saf. 2021;17:e335-e342.

This study used direct observation and interviews to assess hazards in the medication use process in a sample of ambulatory patients who predominantly had low health literacy. The investigators found that the outpatient medication use process is fragmented and complex with poor coordination between clinicians, pharmacists, and insurance companies, forcing patients to develop self-management strategies to manage their chronic health conditions.

Can communication-and-resolution programs achieve their potential? Five key questions.

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Gallagher TH, Mello MM, Sage WM, et al. Health Aff (Millwood). 2018;37:1845-1852.

Communication-and-resolution programs are designed to build healing relationships, offer appropriate compensation, and facilitate organizational learning after a harmful medical error. Although some success has been achieved, communication-and-resolution programs have yet to be widely implemented across the health system. This commentary discusses policy, safety outcome evidence, monetary, and program design weaknesses as prominent barriers to wide-scale implementation. The authors recommend aligning the programs to foundational concepts of safety and patient-centeredness to help drive progress.

Patient Safety.

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Health Aff (Millwood). 2018;37(11):1723-1908.

The Institute of Medicine report, To Err Is Human, marked the founding of the patient safety field. This special issue of Health Affairs, published 20 years after that report, highlights achievements and progress to date. One implementation study of evidence-based surgical safety checklists demonstrated that leadership involvement, intensive activities, and engagement of frontline staff are all critical to successful adoption of safety practices. Another study demonstrated that communication-and-resolution programs either decreased or did not affect malpractice costs, providing further support for implementing such programs. Experts describe the critical role of human factors engineering in patient safety and outline how to enhance the use of these methods. The concluding editorial by David Bates and Hardeep Singh points to progress in reducing hospital-acquired infections and improving medication safety in acute care settings and highlights remaining gaps in the areas of outpatient care, diagnostic errors, and electronic health record safety. In the related information, the Moore Foundation provides free access to five articles in this special issue.

Patient safety culture, health information technology implementation, and medical office problems that could lead to diagnostic error.

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Campione JR, Mardon RE, McDonald KM. J Patient Saf. 2019;15:267-273.

Identifying and addressing diagnostic error in the ambulatory setting remains an ongoing challenge. Incorrect or delayed diagnoses can subject patients to unnecessary testing and delays in care that lead to harm. Using AHRQ safety culture survey results from 925 medical offices across the United States, researchers sought to understand the association between safety culture, health information technology (IT) implementation, and the incidence of problems that could contribute to diagnostic error in outpatient care, such as missing or unavailable test results and records. The most frequently cited problem was missing test results, with about 15% of offices in the study citing that it occurred daily or weekly. Better safety culture scores were associated with fewer problems, and practices undergoing health IT implementation reported more problems. A past WebM&M commentary highlighted an incident involving a delay in cancer diagnosis.

The Lawrence D. Dorr Surgical Techniques & Technologies Award: "Running two rooms" does not compromise outcomes or patient safety in joint arthroplasty.

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Hamilton WG, Ho H, Parks NL, et al. J Arthroplasty. 2018;33:S8-S12.

The practice of scheduling concurrent surgeries—separate procedures performed at overlapping times in different operating rooms by the same surgeon—has been identified as a potential safety risk. This single-institution study found no difference in short- and long-term complication rates for concurrent joint replacement procedures compared to nonconcurrent procedures. Analysis of data from the National Surgical Quality Improvement Program also found no elevated risk to patients from concurrent surgeries.

A multi-hospital before–after observational study using a point-prevalence approach with an infusion safety intervention bundle to reduce intravenous medication administration errors.

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Schnock KO, Dykes PC, Albert J, et al. Drug Saf. 2018;41:591-602.

Intravenous medication administration errors related to smart pumps can compromise patient safety. Prior research has shown that such errors are common and often involve incorrect dosing and workarounds. Researchers describe the development and implementation of a multicomponent safety intervention bundle developed to reduce medication administration errors associated with smart pump use. Although both the overall error rate and medication error rate per 100 medication administrations 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 improve safety.

Pragmatic insights on patient safety priorities and intervention strategies in ambulatory settings.

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Sarkar U, McDonald KM, Motala A, et al. Jt Comm J Qual Patient Saf. 2017;43:661-670.

Patient safety in the ambulatory setting is gaining traction as a focus of research and improvement efforts. Discussing the methods and results of an AHRQ Technical Brief, this commentary summarizes expert opinion on the report to propose recommendations for a research strategy on ambulatory patient safety. The authors outline patient safety practices relevant to the ambulatory setting and suggest activities to advance improvement efforts in outpatient care, such as measure development and use of health information technologies.

Opioid abuse and poisoning: trends in inpatient and emergency department discharges.

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Tedesco D, Asch SM, Curtin C, et al. Health Aff (Millwood). 2017;36:1748-1753.

Using data from the Healthcare Cost and Utilization Project, this retrospective secondary data analysis found an overall increase in opioid-related hospital visits, with a peak in 2010 and gradual decline since then. Coincident with the decline in opioid-related visits, a sharp rise in heroin-related hospital visits emerged. These results underscore the concern that tighter controls on opioid medications may lead to heroin use.

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