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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 - 10 of 10 Results
Carpenter C, Jotte R, Griffey RT, et al. Mo Med. 2023;120:114-120.
AHRQ's 2022 report Diagnostic Errors in the Emergency Department: A Systematic Review, which reported an estimated 7.4 million patients receive a misdiagnosis in the emergency department every year, garnered public, practitioner, and researcher attention. In this peer-reviewed commentary, the authors critique several components of the report. They also support AHRQ's recommended next steps, and further call for additional public and private funding opportunities to continue improving diagnostic accuracy in the emergency department.
Griffey RT, Schneider RM, Todorov AA. J Patient Saf. 2023;19:59-66.
Near-miss incidents present useful learning opportunities but frequently go unreported. This study used a computerized trigger tool to identify near-miss incidents in the emergency department (ED). Results show approximately 23% of ED visits during the 13-month study period included a near-miss incident. This analysis suggests computerized trigger tools can be useful to identify near misses that otherwise go unreported.
Griffey RT, Schneider RM, Todorov AA. Ann Emerg Med. 2022;80:528-538.
Trigger tools are a novel method of detecting adverse events. This article describes the location, severity, omission/commission, and type of adverse events retrospectively detected using the computerized Emergency Department Trigger Tool (EDTT). Understanding the characteristics of prior adverse events can guide future quality and safety improvement efforts.
Griffey RT, Schneider RM, Todorov AA. Jt Comm J Qual Patient Saf. 2020;46:192-198.
Trigger tools are one approach to identifying adverse events. This retrospective cohort study developed an emergency department (ED) trigger tool to characterize adverse events that are present on arrival (POA). The majority (60.8%) of adverse events identified in the ED were POA, accounting for an estimated 7.6% of ED visits. The most comment POA adverse events were medication-related (55.6%).
Griffey RT, Schneider RM, Sharp BR, et al. J Patient Saf. 2020;16:e245-e249.
Measuring adverse events and near misses remains challenging but is essential for improving patient safety. This prospective study of quality and safety review processes across five academic emergency departments over a year-long period found an overall adverse event rate of 1.99%.
Griffey RT, Schneider RM, Adler L, et al. J Patient Saf. 2016;16:e11-e17.
Researchers sought to develop an emergency-department specific trigger tool to identify adverse events. Their Delphi process resulted in a 46-item proposed tool that will require validation and testing in order to determine its usefulness in practice. This formative work fills a gap in available trigger tools.
Farley HL, Baumlin KM, Hamedani A, et al. Ann Emerg Med. 2013;62:399-407.
Many emergency departments (EDs) have recently implemented electronic medical records (EMRs) specifically designed for emergency care. This article evaluates the benefits and potential threats to patient safety of various emergency department information systems (EDISs). Case studies illustrate patient safety pitfalls of inferior EDIS products or of improper implementation. The authors propose seven recommendations for appropriate and safe EDIS deployment, including ED physician engagement, risk transparency from vendors and clients, and a call for legal responsibility from vendors. An AHRQ WebM&M commentary discusses a patient who received an extra dose of vancomycin due to inadequate communication between the EDIS and the hospital EMR.
Griffey RT, Wittels K, Gilboy N, et al. Ann Emerg Med. 2009;53:469-76.
Computerized reminders to renew orders for physical restraints were combined with a forcing function—denial of computer access until the order was completed—in this trial conducted in an emergency department. Although clinician ordering behavior improved, no significant improvement was found in the amount of time patients spent in restraints.
Kachalia A, Gandhi TK, Puopolo AL, et al. Ann Emerg Med. 2007;49:196-205.
This study addressing the causes of missed and delayed diagnoses in emergency department patients used similar methodology as a companion study of error in the ambulatory setting and a prior study of surgical patients. Errors involved a broad range of patients and conditions. As in the outpatient arena, errors generally occurred due to failure to order diagnostic tests or interpret them correctly; factors contributing to error included cognitive factors (ie, physician judgment or knowledge), but system factors (ie, fatigue or communication breakdowns) were involved in a significant proportion of cases. As was also found in the study of ambulatory patients, the multifactorial nature of the errors identifies many potential areas for action but likely defies simple solutions.