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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 33 Results
Grubenhoff JA, Bakel LA, Dominguez F, et al. Jt Comm J Qual Patient Saf. 2023;49:547-557.
Clinical care pathways (CP) standardize care to ensure evidence-based practices are consistently followed. This study analyzed missed diagnostic opportunities (MDO) of pediatric musculoskeletal infections that could have been mitigated had the CP recommendations been adhered to. Misinterpretation of laboratory results was a critical contributor to MDO by both pediatric emergency providers and orthopedic consultants.
Vikan M, Haugen AS, Bjørnnes AK, et al. BMC Health Serv Res. 2023;23:300.
A culture of safety is essential to the delivery of high-quality, safe healthcare. This scoping review including 34 studies found that patient safety culture scores were generally associated with reduced adverse event rates, but the authors note a paucity of research from primary care settings and low- and middle-income countries as well as a need for longitudinal studies using standardized measures to better examine this relationship.
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.

Stein L, Fraser J, Penzenstadler N et al. USA Today. March 10, 2022.

… how COVID affected care in long-term care environments. … Stein L, Fraser J, Penzenstadler N et al. USA Today . March …
Schnipper JL, Reyes Nieva H, Mallouk M, et al. BMJ Qual Saf. 2022;31:278-286.
Medication reconciliation aims to prevent adverse events during transitions of care, but implementing effective interventions supporting medication reconciliation has proven challenging. Building upon lessons learned in the MARQUIS1 study, this pragmatic quality improvement study (MARQUIS2) implemented a refined toolkit including system-level and patient-level interventions as well as physician mentors providing remote coaching and in-person site visits. Across 17 hospital sites, the intervention was associated with a significant decrease in unintentional mediation discrepancies over time.
Leviatan I, Oberman B, Zimlichman E, et al. J Am Med Inform Assoc. 2021;28:1074-1080.
Human factors, such as cognitive load, are main contributors to prescribing errors. This study assessed the relationship between medication prescribing errors and a physician’s workload, successive work shifts, and prescribing experience. The researchers reviewed presumed medication errors flagged by a computerized decision support system (CDSS) in acute care settings (excluding intensive care units) and found that longer hours and less experience in prescribing specific medications increased the risk of prescribing errors.
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.
Rose AJ, Bernson D, Chui KKH, et al. J Gen Intern Med. 2018;33:1512-1519.
High-risk opioid prescribing practices contribute to increased opioid use and opioid-related harm. In this cohort study, researchers found that potentially inappropriate opioid prescribing was associated with increased risk of all-cause mortality and both fatal and nonfatal overdose.
Schnipper JL, Mixon A, Stein J, et al. BMJ Qual Saf. 2018;27:954-964.
The goal of medication reconciliation is to prevent unintended medication discrepancies at times of transitions in care, which can lead to adverse events. Implementing effective medication reconciliation interventions has proven to be challenging. In this AHRQ-funded quality improvement study, five hospitals implemented a standardized approach to admission and discharge medication reconciliation using an evidence-based toolkit with longitudinal mentorship from the study investigators. The toolkit was implemented at each study site by a pharmacist and a hospitalist with support from local leadership. The intervention did not achieve overall reduction in potentially harmful medication discrepancies compared to baseline temporal trends. However, significant differences existed between the study sites, with sites that successfully implemented the recommended interventions being more likely to achieve reductions in harmful medication discrepancies. The study highlights the difficulty inherent in implementing quality improvement interventions in real-world settings. A WebM&M commentary discussed the importance of medication reconciliation and suggested best practices.
Chung CP, Callahan T, Cooper WO, et al. Pediatrics. 2018;142:e20172156.
Reducing the incidence of opioid overdoses and overdose deaths is an essential patient safety priority. In the last decade, children have experienced a dramatic rise in hospitalizations and intensive care unit stays for opioid poisoning. Researchers examined outpatient opioid prescriptions to children who did not have serious illnesses like cancer or sickle cell disease in Tennessee between 1999 and 2014. Dentists prescribed the largest share of more than 1 million opioid prescriptions, followed by surgeons. The authors conclude that 1 in every 2611 prescriptions resulted in an emergency department visit or hospitalization. An accompanying editorial contextualizes the study findings and offers suggestions, such as relying on less toxic analgesics for dental procedures and choosing alternatives to codeine for children who need opioids. A past PSNet perspective examined the patient safety implications of the opioid epidemic.
Compton WM, Jones CM, Stein JB, et al. Res Social Adm Pharm. 2019;15:910-916.
The opioid crisis presents challenges to a wide range of health care professionals. This commentary highlights unique contributions pharmacists can offer to stemming prescription opioid misuse, such as utilizing prescription monitoring tools to help identify problematic behaviors in patients and prescribers, informing patients about risks of opioid use, and recommending addiction treatment for patients at the community level.
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.
Vanderbilt AA, Pappada SM, Stein H, et al. Adv Med Educ Pract. 2017;8:365-367.
Handoffs are vulnerable to communication missteps, and they are further complicated when complex patients such as neonates are involved. This commentary suggests that interprofessional simulation and communication tools can help teams build skills required for reliable and effective handoffs.
Thomas L, Donohue-Porter P, Fishbein JS. J Nurs Care Qual. 2017;32:309-317.
Interruptions and distractions can contribute to medication administration errors. This direct observation study found that interruptions and distractions are frequent during nursing medication administration, which increased cognitive load. These results demonstrate how interruptions affect nursing safety.
Ray WA, Chung CP, Murray KT, et al. JAMA. 2016;315:2415-23.
Opioid use can increase risk of adverse drug events, including overdoses. In this retrospective study, researchers found that the use of long-acting opioids in patients with chronic noncancer pain was associated with greater risk of mortality when compared with patients using other classes of analgesic medications.
Hota B, Webb TA, Stein BD, et al. Jt Comm J Qual Patient Saf. 2016;42:439-446.
Hospital quality rankings, though widely-used, remain controversial. This validation study found inaccuracies in the U.S. News and World Report hospital rankings when compared with Centers for Medicare and Medicaid–measured rates of safety events. The authors state that in response to their findings, the U.S. News and World Report revised their ranking method and data sources.
Rinke ML, Singh H, Ruberman S, et al. Diagnosis (Berl). 2016;3:65-69.
The frequency of diagnostic errors in outpatient care remains unclear. In this survey of outpatient general pediatricians, about one-third reported making a diagnostic error every month. This finding underscores the importance of enhancing the safety of diagnosis in ambulatory settings.
Stein JE, Heiss K. Semin Pediatr Surg. 2015;24:278-82.
Shifting the focus from individual failures to system problems has produced new ways to reduce adverse events. This commentary discusses how human factors research has improved understanding about medical error and the role of teamwork training and safety culture in identifying and addressing safety problems in surgical practice.