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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 222 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%.

Zucchelli G, Stefanini M, eds. Periodontol 2000. 2023;92(1):1-398.

Patient safety in dentistry shares common challenges with medicine and their emergence in a distinct care environment. This special issue covers a range of adverse events and treatment mistakes associated with periodontal procedures. Topics examined include human factors, implant placement and methodologic bias.
Bourkas AN, Barone N, Bourkas MEC, et al. BMJ Open. 2023;13:e068207.
Telemedicine can improve access to specialist care and reduce time to treatment. This systematic review including 44 articles examined the diagnostic agreement between teledermatology and face-to-face consults. The overall average diagnostic agreement was 68.9%, but subgroup analyses identified significantly higher agreement when dermatologists conducted face-to-face and teledermatology consults, rather than non-specialists (i.e., primary care or emergency medicine physicians).
Richman IB, Long JB, Soulos PR, et al. Ann Intern Med. 2023;176:1172-1180.
Overdiagnosis can result in overtreatment, physical harm, and emotional distress. Using SEER-Medicare data, researchers examined breast cancer overdiagnosis by comparing cancer incidence among women who discontinued mammography screening after age 70 compared to women who continued to receive screening mammograms. Findings suggest that breast cancer may be potentially overdiagnosed among 31% of women aged 70 to 74 years, 47% of women aged 75 to 84 years, and 54% of women aged 85 and older who continue to receive screening mammograms.
Wang Y, Eldridge N, Metersky ML, et al. Circ Cardiovasc Qual Outcomes. 2023;16:e009573.
Unplanned hospital readmission and 30-day all-cause mortality rates are indicators of hospital safety. This study analyzed the association of these two indicators with in-hospital adverse events (AE) for patients admitted with heart failure. Results suggest patients with heart failure admitted to hospitals with high rates of 30-day all-cause mortality and readmission are at increased risk for in-hospital AE. The authors describe several possible explanations for these findings.
Newman-Toker DE, Nassery N, Schaffer AC, et al. BMJ Qual Saf. 2023;Epub Jul 17.
Previous research has found that three diseases (vascular events, infections, and cancers) account for approximately 50% of all serious misdiagnosis-related harm. Based on a sample of 21.5 million US hospital discharges, the authors estimated that 795,000 adults in the US experience serious misdiagnosis-related harm (permanent morbidity or mortality) attributable to these three disease categories each year.
Cohen TN, Kanji FF, Wang AS, et al. Am J Surg. 2023;226:315-321.
Intraoperative deaths are rare, catastrophic events. This retrospective review of 154 intraoperative deaths occurring between March 2010 and August 2022 at one academic medical center found that most deaths occurred during emergency procedures. Common contributing factors included coordination challenges, skill-based errors, and environmental factors.
Vaughan-Malloy AM, Chan Yuen J, Sandora TJ. Am J Infect Control. 2023;51:514-519.
Hand hygiene adherence is an essential component of patient safety. Using the SEIPS 2.0 model, this study explored clinician perspectives about high reliability in hand hygiene. The 61 respondents identified several barriers associated with aspects of organizational culture, environment, tasks and tools, including frequently empty alcohol-based hand rub dispensers and challenges with the layout of patient care areas.
Boudreaux ED, Larkin C, Vallejo Sefair A, et al. JAMA Psych. 2023;80:665-674.
Patients who present to the emergency department (ED) with suicidal ideation can benefit from ED-initiated interventions, but interventions can be difficult to implement and maintain. This research builds on a 2013 study, describing the quality improvement (QI) methods used to implement the Emergency Department Safety Assessment and Follow-up Evaluation 2 (ED-SAFE 2) trial. The QI approach was successful in reducing death by suicide and suicide-related acute care during the study period.
Pugh S, Chan F, Han S, et al. J Nurs Adm. 2023;53:292-298.
The COVID-19 pandemic dramatically impacted the delivery of nursing care. This retrospective analysis examined the impact of a bedside checklist and nursing-led intervention bundle (“Nursing Back to Basics” or NB2B bundle) among patients hospitalized with COVID-19 at one academic hospital in New York City. The NB2B bundle, implemented with a bedside checklist, included five evidence-based interventions. Between March and April 2020, the NB2B intervention showed a 12% reduction in mortality due to COVID-19 compared with usual care.
Liberman AL, Wang Z, Zhu Y, et al. Diagnosis (Berl). 2023;10:235-241.
Symptom–Disease Pair Analysis of Diagnostic Error (SPADE) is a framework to measure diagnostic errors using existing databases, such as electronic health records or administrative claims. The original developers of the SPADE framework provide additional guidance on types of comparator groups, how to select the appropriate group, and what inferences can be drawn from the analysis.
Shanafelt TD, West CP, Dyrbye LN, et al. Mayo Clinic Proc. 2022;97:2248-2258.
The COVID-19 pandemic has increased attention on clinician burnout and well-being. This survey of 2,440 US physicians identified an increase in burnout and decrease in satisfaction with work-life integration during the COVID-19 pandemic. Compared with earlier surveys (in 2011, 2014, 2017 and 2020), respondents reported higher mean emotional exhaustion scores, depersonalization scores, and burnout symptoms.
Girotra S, Jones PG, Peberdy MA, et al. Circ Cardiovasc Qual Outcomes. 2022;15:e008901.
Rapid response teams (RRTs) have been implemented at hospitals worldwide, despite mixed results in their effectiveness. The aim of this study was to compare expected mortality rates with mortality rates following RRT implementation, adjusted for hospital case mix. Of 56 hospitals that participated in this project and had complete data, only four showed lower-than-expected mortality rates and two showed higher-than-expected mortality, suggesting RRT may not reduce mortality rates as much as earlier studies have reported.