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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 41 Results
Pitts SI, Olson S, Yanek LR, et al. JAMA Intern Med. 2023;Epub Sep 5.
Previous research has found that CancelRx can improve communication between electronic health record (EHR) systems and pharmacy dispensing systems and increase successful medication discontinuation. This interrupted time series analysis assessed the impact of CancelRx implementation on successful discontinuation of medications e-prescribed in ambulatory healthcare settings. After CancelRx implementation, the proportion of e-prescriptions sold after discontinuation in the EHR decreased from 8.0% to 1.4%.

Abraham J, Rosen M, Greilich PE eds. Jt Comm J Qual Patient Saf. 2023;49(8):341-434.

… … Landgraf … Minnis … Gisick … McBroom … Ambardekar … Olson … ECHO … Abraham … Rosen … Conn … Wu … Anglade … Peifer … K … Minnis E … Gisick L … McBroom M … Ambardekar A … Olson D … ECHO ICU Collaborative … Abraham J … Rosen M … Conn …

Kans J Med. 2023;June 2016:153-171.

… … Hartwell … Barach … Gunter … Reed … Kelker … Welch … Olson … Harry … Meltzer-Brody … Quinn … Ferrand … Kiely … … … Kyra Reed … Heather Kelker … Julie Welch … Kristine Olson … Elizabeth Harry … Samantha Meltzer-Brody … Mariah …
Khazen M, Sullivan EE, Arabadjis S, et al. BMJ Open. 2023;13:e071241.
Improving diagnostic quality is a patient safety priority. In this study, researchers used audio-recorded encounters, clinical note review, and interviews in order to evaluate a tool assessing key elements of diagnostic quality during clinical encounters. Many elements were reliably included in the clinical note or encounter transcript (e.g., follow-up contingencies, red flags) but other elements were often missing (e.g., psychosocial/contextual information). The researchers found that burnout was more common among physicians recording fewer key diagnostic elements.
Keebler JR, Lynch I, Ngo F, et al. Jt Comm J Qual Patient Saf. 2023;49:373-383.
Handoffs are an inevitable part of hospital care; clear communication between providers is required to ensure safe care. This quality improvement project aimed to improve handoffs between the cardiovascular (CV) operating room and CV intensive care unit by developing, implementing, and sustaining a structured handoff bundle. A participatory design was used to ensure that the tool contained only the key elements to support implementation without overburdening users.
Rosner BI, Zwaan L, Olson APJ. Diagnosis (Berl). 2023;10:31-37.
Peer feedback is an emerging approach to improving clinicians’ diagnostic reasoning skills. The authors outline several barriers to diagnostic performance feedback and propose solutions to improve diagnostic performance.
Joseph MM, Mahajan P, Snow SK, et al. Pediatrics. 2022;150:e2022059673.
Children with emergent care needs are often cared for in complex situations that can diminish safety. This joint policy statement updates preceding recommendations to enhance the safety of care to children presenting at the emergency department. It expands on the application of topics within a high-reliability framework focusing on leadership, managerial factors, and organizational factors that support safety culture and workforce empowerment to support safe emergency care for children.
Linzer M, Sullivan EE, Olson APJ, et al. Diagnosis (Berl). 2023;10:4-8.
Challenging working conditions and increased cognitive workload can result in stress and burnout. This article describes a conceptual framework in which working conditions and cognitive workload impact stress and burnout, which, in turn, impacts diagnostic accuracy. Potential uses and testing of the framework are described.
Graber ML, Holmboe ES, Stanley J, et al. Diagnosis (Berl). 2022;9:166-175.
In 2019, a consensus group identified twelve competencies to improve diagnostic education. This article details next steps for incorporating competencies into interprofessional health education: 1) Developing a shared, common language for diagnosis, 2) developing the necessary content, 3) developing assessment tools, 4) promoting faculty development, and 5) spreading awareness of the need to improve education in regard to diagnosis.
Patient Safety Innovation April 7, 2022

Obtaining a best possible medication history is the cornerstone of medication reconciliation but can be resource-intensive. This comparison study assessed the impact of virtual pharmacy technicians (vCPhT) obtaining best possible medication histories from patients admitted to the hospital from the emergency department. 

Marshall TL, Rinke ML, Olson APJ, et al. Pediatrics. 2022;149:e2020045948D.
Reducing diagnostic errors in pediatric care remains a critical area of research and quality improvement. This narrative review presents the incidence and epidemiology of pediatric diagnostic error and strategies for additional innovative research to develop effective interventions to reduce these errors.
Gadallah A, McGinnis B, Nguyen B, et al. Int J Clin Pharm. 2021;43:1404-1411.
This comparison study assessed the impact of virtual pharmacy technicians (vCPhT) obtaining best possible medication histories from patients admitted to the hospital from the emergency department.  The rates of unintentional discrepancies per medication and incomplete medication histories were significantly lower for vCPhT than other clinicians. Length of stay, readmissions, and emergency department visits were similar for both groups.
Fernandez Branson C, Williams M, Chan TM, et al. BMJ Qual Saf. 2021;30:1002-1009.
Receiving feedback from colleagues may improve clinicians’ diagnostic reasoning skills. By building on existing models such as Safer Dx, and collaborating with professionals outside of the healthcare field, researchers developed the Diagnosis Learning Cycle, a model intended to improve diagnosis through peer feedback.
Gleason KT, Harkless G, Stanley J, et al. Nurs Outlook. 2021;69:362-369.
To reduce diagnostic errors, the National Academy of Medicine (NAM) recommends increasing nursing engagement in the diagnostic process. This article reviews the current state of diagnostic education in nursing training and suggests inter-professional individual and team-based competencies to improve diagnostic safety.
WebM&M Case September 25, 2019
… of cancer cells by the chemotherapy drugs. The patient's oncologist was contacted, who agreed with this provisional … to address the electrolyte abnormalities. The patient's blood pressure improved with fluids. Further laboratory … was not considered. … The Commentary … by Andrew P. Olson, MD The art of diagnosis involves collecting and then …
Olson A, Rencic J, Cosby K, et al. Diagnosis (Berl). 2019;6:335-341.
Mitigating diagnostic error has become a critical patient safety concern. As a result, medical education and training programs are increasingly focused on teaching students and residents about diagnostic safety. This article describes the development of a novel interprofessional framework to improve diagnostic competency across health professions education programs. A consensus committee identified 12 key competencies that focus on individual performance (e.g., prioritizing differential diagnosis; utilizing second opinions, decision support, and checklists), teamwork (e.g., engaging patients and families; collaborating with other health professionals), and system-related aspects of clinical care (e.g., developing a culture of diagnostic safety; disclosing and learning from errors). The authors emphasize the innovative aspects of their recommendations and suggest that education programs develop curriculum incorporating these competencies to improve diagnosis. A previous WebM&M commentary discussed an incident involving a diagnostic error.

Dhaliwal G, Olson APJ, Singhal G, eds. Diagnosis (Berl). 2019;6(2):75-185.

Clinical and educational environments are increasingly focusing on improving diagnosis. This special issue explores an overarching approach to designing medical education strategies to address known weaknesses that affect diagnostic safety. Articles in the issue discuss the use of technology, diagnosis education, diagnostic processes in clinical contexts, and multidisciplinary improvement strategies.
Pawloski PA, Brooks GA, Nielsen ME, et al. J Natl Compr Canc Netw. 2019;17:331-338.
In this systematic review, researchers sought to evaluate the impact of clinical decision support (CDS) on the quality and safety of care provided to cancer patients. Most of the studies included in the study demonstrated improved outcomes related to the use of CDS, but the authors conclude that more rigorous research regarding the impact of CDS on clinical outcomes for oncology patients is needed.