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
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Narrow Results By
Search By Author(s)
PSNet Original Content
Commonly Searched Resource Types
Additional Filters
Displaying 1 - 12 of 12 Results
Wallis CJD, Jerath A, Coburn N, et al. JAMA Surg. 2022;157:146-156.
Gender, racial, and ethnic disparities in healthcare can adversely impact patient safety and lead to poor outcomes. This retrospective study examined surgeon-patient sex discordance and perioperative outcomes among adult patients in Ontario, Canada, undergoing common elective or emergent surgical procedures from 2007 to 2019. Among 1.3 million patients, sex discordance between surgeon and patient was associated with a significant increased likelihood of adverse perioperative outcomes, including death. Subgroup analyses indicate that this relationship is driven by worse outcomes among female patients treated by male surgeons.
Taran S, Detsky AS. JAMA Intern Med. 2019;179:1019–1020.
This commentary draws parallels between experiences in viewing and exploring meaning in modern art to the challenge of diagnosis. The author discusses how experiences, values, and opinions can affect the interpretation and influence decision-making.
Judson TJ, Press MJ, Detsky AS. Healthc (Amst). 2019;7:4-6.
Health care is working to provide high-value care and prevent overuse while ensuring patient safety. This commentary highlights the importance of educational initiatives, mentors, and use of clinical decision support to help clinicians determine what amount of care is appropriate for a given clinical situation.
Delgado K, Shofer FS, Patel MS, et al. J Gen Intern Med. 2018;33:409-411.
To reduce opioid risk, the Centers for Disease Control and Prevention recommend that frontline providers minimize the number of opioid tablets they prescribe for acute pain. This pre–post study examined the effect of implementing a 10-tablet default prescription in the electronic medical record in two urban emergency departments. The intervention changed prescribing habits but did not reduce the already low overall number of tablets prescribed. Two PSNet perspectives explore the intersection of patient safety and the opioid epidemic.
Gupta S, Saint S, Detsky AS. JAMA Intern Med. 2017;177:757-758.
Reliance on information technology has surfaced a myriad of unintended consequences. This commentary highlights the importance of the physician–patient encounter and how such interactions have diminished with the implementation of electronic health records. The authors caution against the downsides of heuristics, cognitive errors, and implicit bias during the initial exam and underscore the value of contextual information gathered from personal interaction.
Detsky AS. JAMA. 2016;316:1043-4.
Storytelling has been advocated as a strategy to teach and augment awareness in patient safety. In this commentary, the author relates a personal anecdote to illustrate how assumptions can affect clinical reasoning and provides lessons to broaden clinician thinking when working toward determining a diagnosis.
Lane-Fall MB, Collard ML, Turnbull AE, et al. Crit Care Med. 2016;44:690-8.
This survey of academic intensivist physicians found that although most reported participating in end-of-shift handoffs, the handoff process varied across institutions. Satisfaction with handoff procedures was suboptimal, and a significant proportion of respondents could recall an adverse event related to handoffs. This suggests that despite extensive work in this area, handoffs remain a persistent safety vulnerability.
Katz D, Detsky AS. J Hosp Med. 2016;11:120-2.
Cognitive gaps and shortcuts, or heuristics, can result in diagnostic mistakes. This commentary explores decision making in health care and suggests incorporating education about cognitive heuristics into morbidity and mortality rounds to inform improvement efforts and enhance care safety.