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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 22 Results
Bicket MC, Waljee JF, Hilliard P. JAMA Health Forum. 2022;3:e221356.
Concern for improved prescribing of opiates motivated the development of programs and policies that have inadvertently caused new problems. This commentary discusses the impact of nonopioid use during surgery as a patient preference. It discusses the potential for adverse impacts of the strategy while recognizing the unique situation of perioperative use of pain medications.
Chua K-P, Brummett CM, Conti RM, et al. Pediatrics. 2021;148:e2021051539.
Despite public policies and guidelines to reduce opioid prescribing, providers continue to overprescribe these medications to children, adolescents, and young adults. In this analysis of US retail pharmacy data, 3.5% of US children and young adults were dispensed at least one opioid prescription; nearly half of those included at least one factor indicating they were high risk. Consistent with prior research, dentists and surgeons were the most frequent prescribers, writing 61% of all opiate prescriptions.
Barth RJ, Waljee JF. JAMA Surg. 2020;155:543-544.
This commentary discusses the harms of opioid overprescribing, particularly among opioid-naïve patients. The authors suggest that opioid dependence, abuse, or overdose in an opioid-naïve patient undergoing surgery should be considered a “never event” and discuss strategies for appropriate prescribing by surgeons.
Agarwal S, Bryan JD, Hu HM, et al. JAMA Netw Open. 2019;2:e1918361.
In 2016, the Centers for Disease Control and Prevention (CDC) issued opioid prescribing guidelines that recommended limiting the duration of therapy for acute pain. Research has found that the guidelines have changed opioid prescribing in the emergency department, but less is known about the impact on postoperative opioid prescribing. This study examined the effect of opioid prescribing duration limits in Massachusetts and Connecticut on postoperative prescribing. Dosing duration limits resulted in decreases in postoperative prescription size and days supplied in Massachusetts but not in Connecticut.
Sheetz KH, Dimick JB, Englesbe MJ, et al. Health Aff (Millwood). 2019;38:1858-1865.
Since 2013, Medicare’s Hospital-Acquired Condition Reduction Program (HACRP) has reduced payments to hospitals with elevated rates of specific outcomes deemed to be preventable sources of harm. To better understand the impact of the HACRP in Michigan, this study used a surgical registry to compare trends in rates of outcomes targeted by the program to concurrent trends for other hospital-acquired conditions, such as postoperative cardiac arrest and postoperative pneumonia. The authors saw an overall decrease in all hospital-acquired conditions over the eight-year study period but did not identify a statistically significant change in the rate of HACRP-targeted versus non-targeted conditions. The authors acknowledge that these findings may not be generalizable nationally because of robust quality improvement efforts already in place in Michigan, such as existence of other quality improvement efforts, such as the AHRQ-recognized Michigan Surgical Quality Collaborative and the Hospital Engagement Network
Harbaugh CM, Lee JS, Chua K-P, et al. JAMA Surg. 2019;154:e185838.
This retrospective cohort study found that adolescent patients who received opioids for surgical and dental procedures were more likely to develop persistent opioid use if they had family members with long-term opioid use. The study team recommends preoperative screening for long-term opioid use in family members as part of prescribing decision-making for adolescent patients.
Howard R, Fry B, Gunaseelan V, et al. JAMA Surg. 2019;154:e184234.
This observational study found that when patients were prescribed a higher number of opioid pills following surgery, they self-administered more pills, although most patients did consume all of the pills they received. The authors suggest collecting patient-reported opioid consumption data in order to make opioid prescribing safer.
Habbouche J, Lee JS, Steiger R, et al. JAMA Surg. 2018;153:1111-1119.
Various regulatory and policy initiatives are being implemented to encourage more responsible opioid prescribing in the face of the ongoing opioid epidemic. One such federal initiative, implemented by the Drug Enforcement Agency in 2014, was to change hydrocodone to a schedule II agent, which restricted hydrocodone to a 90-day supply that could not be prescribed or refilled by telephone. This study examined the effect of the change on hydrocodone prescribing for patients in Michigan who had undergone elective surgery, using a database that measured opioid prescriptions filled by patients. Implementation of the new regulation was associated with an unexpected increase in the amount of opioids filled initially after surgery. Although prescription refill rates decreased, overall there was no significant difference in the total amount of opioids prescribed within the 30-day postoperative period after the schedule change was implemented. The authors hypothesize that the increased restrictions on hydrocodone prescribing may have resulted in surgeons giving larger initial prescriptions in order to ensure postoperative pain control. The effect of national regulatory initiatives on opioid prescribing remains unclear at present, but recent studies have shown that personalized feedback to prescribers may be effective at improving prescribing.
Harbaugh CM, Lee JS, Hu HM, et al. Pediatrics. 2018;141:e20172439.
Opioid misuse is an urgent patient safety issue. Research has found that a significant proportion of adults prescribed opioids in the short term remain on opioid medications chronically, but less is known about postsurgical opioid use among pediatric patients. This study analyzed a large, commercial health care claims database to determine whether children and adolescents prescribed opioids following surgery were more likely to be prescribed opioids 3 to 6 months later, compared to children who did not undergo surgery. Researchers found that postoperative opioid use was associated with persistent opioid use. A related editorial raises questions about the breadth of procedures included and calls for development and implementation of evidence-based pediatric pain management strategies that address the risk for persistent opioid use and misuse.
Howard R, Waljee JF, Brummett CM, et al. JAMA Surg. 2018;153:285-287.
This pre–post study examined the effect of implementing an evidence-based opioid prescribing guideline following cholecystectomy surgery. After guideline implementation, the average number of opioid pills per prescription declined, but no increase in refill requests occurred. More patients were prescribed nonopioid pain medications after guideline implementation than before. These promising results suggest a path toward reducing the use of these high-risk medications.
Dossett LA, Kauffmann RM, Lee JS, et al. Ann Surg. 2018;267:1077-1083.
Prior studies demonstrate that disclosure of medical errors to patients is central to maintaining a therapeutic provider–patient relationship. However, little is known about physicians' beliefs regarding the disclosure of other clinicians' errors. Investigators interviewed 30 oncologists to understand their attitudes toward disclosure of medical errors occurring prior to the referral of a patient. Most believed that error disclosure did not benefit patients and disclosure practices varied significantly.
Lee JS, Hu HM, Brummett CM, et al. JAMA. 2017;317:2013-2015.
The opioid crisis is one of the nation's most pressing patient safety problems. Concern has been raised that overprescribing of opioids may be an unintended consequence of efforts to improve patient satisfaction. However, this Michigan study found no relationship between postoperative opioid prescribing and patient satisfaction scores, indicating that efforts to reduce opioid prescribing may not adversely affect patient satisfaction.
Brummett CM, Waljee JF, Goesling J, et al. JAMA Surg. 2017;152:e170504.
Opioid medication use represents a significant safety problem in the United States. Overprescribing by providers is one factor contributing to the widespread use of opioids. Reducing inappropriate prescribing may help improve patient safety. Using claims data for 36,177 patients, investigators sought to better characterize new and persistent opioid use after surgery, defined as filling an opioid prescription between 90 and 180 days postoperatively. Although there was no major difference in persistent opioid use between those who underwent minor surgical procedures and those who underwent major surgical procedures, results demonstrated that opioid use persisted in greater frequency after surgery among patients with behavioral, pain, and substance use disorders. A recent PSNet perspective discussed patient safety with regard to opioid medications.
Pradarelli J, Campbell D, Dimick JB. JAMA. 2015;313:1313-4.
Learning curves with new devices can hinder patient safety. This commentary explores legal and accountability issues associated with the use of the da Vinci surgical system, particularly whether the hospital or physician is responsible for training, credentialing, and privileging to utilize the device. The authors suggest that the hospital be responsible for providing opportunities to develop skills and confirm that physicians are prepared to safely use new technologies.
Reames BN, Krell RW, Campbell D, et al. JAMA Surg. 2015;150:208-15.
Initial enthusiasm for the role of checklists in reducing perioperative complications has been tempered by subsequent studies that did not replicate the safety improvements. This study evaluated the effect of the Keystone Surgery program, which combined an evidence-based checklist and the comprehensive unit-based safety program to enhance safety culture. Comparison of Keystone Surgery hospitals to those that did not implement the intervention found no differences in outcomes (including surgical site infections and 30-day mortality) between groups. The investigators acknowledge that many participating sites lacked the infrastructure to collect and regularly feed back performance data to frontline providers, which may have limited the effectiveness of the intervention. The study adds to a growing body of literature that emphasizes the role of effective implementation and monitoring in ensuring the success of checklist-based interventions. A PSNet interview and perspective explore the development and use of checklists to augment safety in health care.
Patel SP, Gauger PG, Brown DL, et al. J Am Coll Surg. 2010;211:540-5.
Do resident physicians contribute disproportionately to medical errors? The evidence is mixed, despite the longstanding concern about a purported increase in errors in July, when most new residents start their training. This study compared complication rates in breast reduction surgery between surgical residents and an attending physician, and found no evidence of increased complications in procedures performed primarily by residents with close attending supervision. However, poor supervision of residents has resulted in substandard care in other settings.
Khuri SF, Henderson WG, Daley J, et al. Ann Surg. 2008;248:329-36.
The Patient Safety in Surgery study documented remarkable improvements in postoperative outcomes at Veterans Affairs hospitals following implementation of a quality improvement program. This study demonstrated similar improvement in clinical outcomes, including surgical site infection rates, following implementation of the program in private sector hospitals.