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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 25 Results
Michelson KA, Bachur RG, Grubenhoff JA, et al. J Emerg Med. 2023;65:e9-e18.
Missed diagnosis in the emergency department can result in unplanned hospitalization due to complications from worsening symptoms. In this study, pediatric patients with and without missed emergency department diagnosis were compared to determine differences in outcomes and hospital utilization. Children with missed diagnosis of appendicitis or new-onset diabetic ketoacidosis experienced more complications, hospital days and readmissions; there was no difference for sepsis diagnosis.
Kamta J, Fregoso B, Lee A, et al. Prehosp Emerg Care. 2023;Epub Jul 28.
Handoffs from emergency medical services (EMS) to the emergency department (ED) are vulnerable to communication errors due to the time-pressured environment. This study reports on the implementation of an electronic health record (EHR) tool that added pre-hospital medication administration to the ED triage note to reduce medication administration errors (MAE). Although most ED providers reported they "always" review the triage note, MAE rates did not improve following implementation.
Hunter J, Porter M, Williams B. Australas Emerg Care. 2023;26:96-103.
Situational awareness (SA) requires recognizing situations, interpreting them, and predicting how the situation may unfold in the future. Paramedics and emergency medical technicians (EMT) participated in a video simulation to assess their SA at each of the three stages. Quantitative results indicated the providers were not situationally aware during the simulation.
Plint AC, Newton AS, Stang A, et al. BMJ Qual Saf. 2022;31:806-817.
While adverse events (AE) in pediatric emergency departments are rare, the majority are considered preventable. This study reports on the proportion of pediatric patients experiencing an AE within 21 days of an emergency department visit, whether the AE may have been preventable, and the type of AE (e.g., management, diagnostic). Results show 3% of children experienced at least one AE, most of which were preventable.
McDonald EG, Wu PE, Rashidi B, et al. JAMA Intern Med. 2022;182:265-273.
Deprescribing is one intervention to reduce the risk of adverse drug events, particularly in older adults and people taking five or more medications. In this cluster randomized trial, older adults (≥65 years) taking at least five medications at hospital admission were randomly assigned to intervention (personalized reports of deprescribing opportunities) or control. Despite an increase in deprescribing in both groups, there was no difference in adverse drug events or adverse drug withdrawal events.
Cooper A, Carson-Stevens A, Edwards M, et al. Br J Gen Pract. 2021;71:e931-e940.
In an effort to address increased patient demand and resulting patient safety concerns, England implemented a policy of general practitioners working in or alongside emergency departments. Thirteen hospitals using this service model were included in this study to explore care processes and patient safety concerns. Findings are grouped into three care processes: facilitating appropriate streaming decisions, supporting GPs’ clinical decision making, and improving communication between services.
Samad F, Burton SJ, Kwan D, et al. Pharmaceut Med. 2021;35:1-9.
Vaccine errors can hinder immunization efforts in the United States. In this article, the authors summarize errors involving 2-component vaccines, discuss safe practices for storing, preparing, dispensing, and administering 2-component vaccines, and highlight risk reduction strategies.

Durning S, Holmboe E, Graber ML, eds. Diagnosis(Berl). 2020;7(3):151-344.

… to education, assessment , and research.     … Durning S, Holmboe E, Graber ML, eds. Diagnosis(Berl) . … … D … J … V … M … M … R … AR … A … M … PA … PW … E … T … S … J … JS … EM … E … G … SM … A … S … A … SJ … AR … LD … E … … Artino … Gruppen … Wilson … Wilhite … Hardowar … Fisher … Porter … Wallach … Altshuler … Hanley … Zabar … Gillespie … …
Habli I, Lawton T, Porter Z. Bull World Health Organ. 2020;98:251-256.
Using clinical artificial intelligence as an example, these authors posit that digital tools are challenging standard clinical practices around assigning blame and assuring patient safety. They discuss moral accountability for harm to patients and safety assurances to protect patients against such harm, and examine these issues from both a clinician and patient perspective.
McDonald EG, Wu PE, Rashidi B, et al. J Am Geriatr Soc. 2019;67:1843-1850.
This pre–post study compared patients who received medication reconciliation that was usual care at the time of hospital discharge to patients in the intervention arm who had decision support for deprescribing. Although the intervention did lead to more discontinuation of potentially inappropriate medications, there was no difference in adverse drug events between groups. The authors suggest larger studies to elucidate the potential to address medication safety using deprescribing decision support.
Trinkley KE, Weed HG, Beatty SJ, et al. Am J Med Qual. 2017;32:518-525.
Adverse drug events are prevalent in outpatient care. In this study, pharmacists and physicians reviewed electronic health records and conducted telephone interviews with patients to determine whether they experienced an adverse drug event during a change in medications. Less than 10% of patients experienced an adverse drug event, which the authors conclude represents an improvement compared to prior studies.
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.
Clanton J, Gardner A, Subichin M, et al. Am J Surg. 2017;213:299-306.
Prior research suggests that implementing a standardized handoff process helps reduce medical errors. This randomized trial compared a formal patient handoff process to a focused one over a 10-month period at a large teaching hospital and found no impact on patient outcomes. The authors suggest that a more efficient handoff process may save time without compromising patient care.
Porter E, Barcega B, Kim TY. West J Emerg Med. 2014;15:486-90.
This study evaluated medication errors made by emergency medicine trainees participating in a simulated resuscitation of a critically ill child. A medication error was committed in more than one quarter of simulations overall, but the presence of a clinical pharmacist during the resuscitation significantly reduced errors.
Porter AJ, Narimasu JY, Mulroy MF, et al. Jt Comm J Qual Patient Saf. 2014;40:3-9.
While surgical safety checklists have proven very effective at minimizing perioperative complications, their implementation in real-world settings has been challenging. In this study, formalizing the checklist process to mandate involvement of all team members improved adherence to appropriate checklist usage.