Skip to main content

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.

Search All Content

Search Tips
Filter By Author(s)
Advanced Filtering Mode
Date Ranges
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Additional Filters
Displaying 1 - 6 of 6 Results
Kraemer KL, Althouse AD, Salay M, et al. JAMA Health Forum. 2022;3:e222263.
Nudges (e.g., default order sets) in the electronic health record (EHR) have been shown to encourage safer prescribing of opioids in emergency departments. This study evaluated the effect of nudges to reduce opioid prescribing for opioid-naïve patients with acute pain. Primary care practices were cluster randomized to control, opioid justification in the EHR, peer comparison, or combined opioid justification and peer comparison groups. The three intervention groups showed reduced opioid prescribing compared to control.
Atallah F, Hamm RF, Davidson CM, et al. Am J Obstet Gynecol. 2022;227:b2-b10.
The reduction of cognitive bias is generating increased interest as a diagnostic error reduction strategy. This statement introduces the concept of cognitive bias and discusses methods to manage the presence of bias in obstetrics such as debiasing training and teamwork.
Szymusiak J, Walk TJ, Benson M, et al. Ped Qual Saf. 2019;4:e167.
Encouraging adverse event reporting among health care providers, including medical trainees, is critical to improving patient safety. This qualitative study convened focus groups to elucidate what factors support event reporting among medical residents. Residents were more likely to use reporting tools when they had received training about the process, and identified specific interventions, to encourage reporting, such as role modeling by faculty.
Wu AW, McCay L, Levinson W, et al. J Patient Saf. 2017;13:43-49.
Based on a series of international expert meetings, this qualitative analysis identified key challenges in error disclosure: policy implementation, patient expectations, confidentiality and legal privilege, aligning disclosure with liability, and documenting and tracking disclosure. These barriers suggest that multiple actions are needed to bolster disclosure efforts. The authors advocate for collaboration between health systems and policymakers, enhanced patient and provider education to foster a blame-free safety culture, and establishment of standard metrics to document and benchmark disclosure across institutions. In a past AHRQ WebM&M perspective, Dr. Albert Wu discussed the importance of disclosing adverse events.
Kraman SS, Hamm G. Ann Intern Med. 1999;131:963-967.
This article reviews a humanistic risk management policy. The authors discuss principles of such a policy, including early injury review, maintenance of the hospital-patient relationship, full disclosure, and fair compensation for injuries. The experiences of one Veterans Affairs medical center are presented to illustrate the role a humanistic policy can play in controlling liability payments. The authors examine the complexity of embracing this proposed strategy while weighing the factors that lead to claims being filed. They conclude by suggesting that prioritizing patients’ interests may reduce expenses associated with malpractice claims.