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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 - 13 of 13 Results
Kalenderian E, Bangar S, Yansane A, et al. J Patient Saf. 2023;19:305-312.
Understanding factors that contribute to adverse events (AE) is key to preventing them from recurring. This study used an electronic trigger tool to identify potential AE in two dental practices. Of 439 charts reviewed, 13% contained at least one AE. The most common AE was post-procedural pain; the expert panel reported 21% of those AEs were preventable. Person-related factors (e.g., supervision, fatigue) were the most common contributing factors.
Yansane A, Tokede O, Walji MF, et al. J Patient Saf. 2021;17:e1050-e1056.
Clinician burnout is a known threat to patient safety. This survey of a national sample of dentists found that approximately 1 in 10 respondents reported high levels of burnout and 50% of respondents reported a perceived dental error in the last 6 months. Efforts to minimize burnout among dentists may help improve patient safety.
Perspective on Safety December 22, 2020

This piece discusses prevalent adverse events in dental care and the challenges in identifying these patient safety events.

This piece discusses prevalent adverse events in dental care and the challenges in identifying these patient safety events.

Muhammad Walji

Elsabeth Kalenderian, DDS, MPH, PhD is a professor at UCSF. Muhammad F. Walji, PhD is the Associate Dean for Technology Services and Informatics and professor for Diagnostic and Biomedical Sciences at the UT Health Science Center at Houston, School of Dentistry. We spoke to them about the identification and prevention of adverse events in dentistry.   

Obadan-Udoh E, Panwar S, Yansane A-I, et al. J Evid Based Dent Pract. 2020;20:101424.
Patient safety events are common in dentistry. A survey administered to adult dental patients found that a majority of them were concerned about their safety at the dental office but that those concerns were not routinely shared with dental providers or clinic staff. Efforts to improve patient engagement and speaking up behaviors can improve safety in dentistry.
Wright A, Ai A, Ash JS, et al. J Am Med Inform Assoc. 2018;25:496-506.
Clinical decision support (CDS) includes electronic alerts that can prevent errors. Excessive or erroneous alerts may lead to alert fatigue or other unintended consequences. Researchers used a blend of qualitative methods such as interviews and quantitative data like alert rates to develop a taxonomy of CDS alert errors. The taxonomy includes the origin of the error, which most commonly occurred with introduction of a new decision support rule, and describes the underlying reason for the error, such as problems with new terms, conceptualization, and building the rule as intended. Errors could cause an alert to fail to appear for a relevant situation or could cause an irrelevant or erroneous alert to appear. Most errors came to light through reports from users. The authors recommend classifying CDS alert errors using this taxonomy so that safety efforts will be consistent and actionable.
Kalenderian E, Obadan-Udoh E, Maramaldi P, et al. J Patient Saf. 2021;17:e540-e356.
In this study, researchers developed and tested classification schemes for types and severity of adverse events in dentistry using medical record review and expert consensus. Pain and infection were the most common types of adverse events in the cases reviewed.
Perspective on Safety August 1, 2016
This piece examines patient safety issues unique to dental care along with strategies to reduce risks.
This piece examines patient safety issues unique to dental care along with strategies to reduce risks.
Dr. Perea-Pérez is Director of the Spanish Observatory for Dental Patient Safety. We spoke with him about patient safety in dentistry.
Wright A, Hickman T-TT, McEvoy D, et al. J Am Med Inform Assoc. 2016;23:1068-1076.
Although clinical decision support is a key patient safety strategy, it may also have unintended consequences. Investigators analyzed clinical decision support system malfunctions and surveyed chief medical informatics officers about such incidents. Nearly all health systems experience decision support malfunctions, and the majority of respondents' health systems had at least one within the last 12 months. Detailed examination of several specific cases found that software updates, differences in data fields and codes, unintended enabling and disabling of rules, and technical problems with other systems all resulted in decision support malfunctions. These vulnerabilities often remain undetected and lead to irrelevant or erroneous alerts, which in turn contribute to alert fatigue. The authors suggest that clinical decision support requires more robust testing and monitoring to reach its potential as a patient safety tool.
Ramoni R, Walji MF, Tavares A, et al. J Dent Edu. 2014;78:745-756.
Researchers administered the AHRQ Medical Office Survey on Patient Safety Culture at three dental schools in the United States and determined that safety culture in dentistry is lacking. A past AHRQ WebM&M commentary describes a wrong-site dental surgery and recommends strategies to reduce risk of errors in this setting.