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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 55 Results
Weingart SN, Nelson J, Koethe B, et al. Cancer Med. 2020;9:4447-4459.
Using a cohort of adults diagnosed with breast, colorectal, lung or prostate cancer, this study examined the relationship between oncology-specific triggers and mortality. It found that patients with at least one trigger had a higher risk of death than patients without a trigger; this association was strongest for nonmetastatic prostate cancer and nonmetastatic colorectal cancer. Triggers most commonly associated with increased odds of mortality were bacteremia, blood transfusion, hypoxemia and nephrology consultation. These findings support the validity of cancer-specific trigger tool but additional research is needed to replicate these findings.
Weingart SN, Yaghi O, Barnhart L, et al. Appl Clin Inform. 2020;11.
To decrease the risk of diagnostic errors attributed to incomplete recommended diagnostic tests, this study evaluated an electronic monitoring tool alerting clinicians to incomplete imaging tests for their ambulatory patients. Compared to the control group (physicians not receiving alerts for their patients), after 90-days the intervention group had a higher rate of imaging completion (22.1% vs. 18.8%); this difference was sustained throughout the 12-month follow-up period (25.5% completion in the intervention group versus 20.9% in the control group). The authors found that this change was primarily driven by completion rates among patients referred for mammography.  To fully appreciate the implications of missed test notifications to reduce the risk of delayed diagnoses, more studies are necessary.
Prentice JC, Bell SK, Thomas EJ, et al. BMJ Qual Saf. 2020;29:883-894.
This article describes results of a cross-sectional recontact survey of Massachusetts residents on the persisting impacts of medical errors. Over half of respondents on the self-reporting a medical error 3-6 years ago survey stated at least one emotional impact, avoiding the doctor(s) or facility(s) involved in the error, and two-thirds of respondents reported a loss of trust after the medical error. Logistical regression analyses, controlling for error severity, suggests that open communication can reduce persistent emotional impacts and avoidance of doctors/facilities involved in the error.
Weingart SN, Nelson J, Koethe B, et al. Cancer Med. 2020;9:1462-1472.
Research has found that trigger tools perform poorly in cancer care. This cohort study comprised of adult patients undergoing treatment for breast, colorectal, lung or prostate cancer investigated the feasibility of a cancer-specific claims-based trigger tool to identify patients with potential adverse events. Results found that triggers affected 19% of patients during their initial year in treatment, and that trigger burden varied by disease, stage, and patient demographics. The most prevalent triggers were abnormal lab test results, blood transfusions, orders for non-contrast CT after chest radiation, and hypoxemia.
Weingart SN, Atoria CL, Pfister D, et al. J Patient Saf. 2021;17:e701-e707.
This retrospective cohort study identified frequent treatment-related adverse events for patients with breast, colorectal, or lung cancer, with 34% of patients experiencing an adverse event during their treatment course. Advanced disease and chemotherapy conferred higher risk for adverse events, as did non-White race and Hispanic ethnicity. The authors suggest that such factors could be used for prospective identification of patients at highest risk for adverse events.
Weingart SN, Zhang L, Sweeney M, et al. Lancet Oncol. 2018;19:e191-e199.
Chemotherapy errors can result in serious patient harm. This review summarized the evidence on chemotherapy errors. Most studies were performed in single-institution academic settings and few studies examined how health information technology affects patient outcomes.
Weingart SN, Weissman JS, Zimmer KP, et al. Int J Qual Health Care. 2017;29:521-526.
… Care … Patient engagement is increasingly recognized as a priority for patient safety efforts. This study team developed and tested a reporting system for patients and families to bring safety … patient safety reporting, not all reports were related to a safety concern. The most common category of mistakes …
Weingart SN, Stoffel EM, Chung DC, et al. The Joint Commission Journal on Quality and Patient Safety. 2016;43.
… Quality and Patient Safety … Delayed cancer diagnosis is a critical patient safety concern in primary care. Rectal … important issue to recognize promptly, because it may be a symptom of colon cancer, for which delayed diagnosis can … and accurate diagnosis in the outpatient setting. In a related editorial, Hardeep Singh suggests that enhancing …
Abookire SA, Gandhi TK, Kachalia A, et al. Am J Med Qual. 2016;31:27-30.
… J Med Qual … This commentary describes the development of a quality and safety clinical fellowship curriculum which … training for these principles in an operational setting. A companion article explores the implementation of this …
Okoroh JS, Uribe EF, Weingart SN. J Patient Saf. 2017;13:153-161.
Prior studies have raised the concern that minorities may be at higher risk of adverse events while hospitalized. This systematic review sought to examine racial and ethnic disparities in studies of patient safety. The authors found that safety research does not uniformly include ethnically diverse populations or adjust for individual characteristics such as race, ethnicity, and income. Hospital-level variations (such as teaching status and percentage of minority patients) and geographic characteristics, both thought to affect disparities in health care outcomes, were not always reported or taken into account in the studies identified. In order to improve characterization of the role disparities play in adverse events, the authors call for research to include reporting of comorbid conditions, sociodemographic characteristics, differences in hospital levels, and geographic factors.
Li JW, Morway L, Velasquez A, et al. J Patient Saf. 2015;11:42-51.
Print news media describes errors in cancer care from patient or legal perspectives more frequently than from clinician or safety expert perspectives. A significant proportion of articles ascribe blame to clinicians and hospital systems and do not discuss systems approaches.
Weingart SN, Carbo AR, Tess A, et al. J Patient Saf. 2013;9.
In the outpatient setting, patients frequently experience adverse events between clinician visits, and many of these may go undetected. This randomized controlled trial sought to evaluate a novel method of engaging patients in safety in order to identify and prevent adverse drug events (ADEs) in outpatients. Patients who were enrolled in an online patient portal (which allowed them to view their own laboratory results and communicate directly with their clinicians) were randomized to be sent automated queries after receiving a new prescription. The queries confirmed whether the prescription was filled and asked questions to detect potential ADEs. Nearly half of the intervention group patients responded to a query and many prescription problems were discovered, but the overall rate of ADEs was no different than the control group (which was enrolled in the portal but did not receive the medication safety messages).
Weingart SN, Zhu J, Young-Hong J, et al. J Oncol Pharm Pract. 2014;20:163-71.
In this study, computer alerts for possible drug interactions between chemotherapy orders and ambulatory medications sometimes led physicians to change their orders, which could prevent adverse drug events in these vulnerable patients.
Walsh KE, Roblin DW, Weingart SN, et al. Pediatrics. 2013;131:e1405-14.
The ability to treat many types of cancer with oral chemotherapy has benefited patients by minimizing hospitalizations, but it also places the burden to avoid medication errors on them as they must administer risky medications correctly. Prior studies have shown that adults and children with cancer are particularly vulnerable to medication errors and that most oncology practices do not have specific safeguards in place to improve oral chemotherapy medication safety. This study used direct observation (during home visits) to determine the epidemiology of medication errors among children with cancer and found a staggeringly high incidence of 36 potentially harmful errors per 100 patients—higher than some studies of hospitalized patients. The authors judged that more than one-third of the errors could have been prevented by better communication between patients and physicians.
WebM&M Case May 1, 2013
A cancer patient expecting to be discharged from the hospital after his usual 3-day regimen was surprised to hear that he has 2 more days of chemotherapy. He asked to speak with the oncology team, who discovered that although the right medications were ordered, the wrong duration and dosage were selected on the order set.