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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 45 Results
Sheikh A, Coleman JJ, Chuter A, et al. Programme Grants Appl Res. 2022;10:1-196.
… Appl Res … Electronic prescribing (e-prescribing) is an established medication error reduction mechanism. This … of the system was a complex endeavor. The effort produced an accompanying toolkit to assist organizations in … e-prescribing system decision making. … Sheikh A, Coleman J, Chuter A, et al.  Programme Grants Appl Res.  2022;10(7): …
Carlile N, Fuller TE, Benneyan JC, et al. J Patient Saf. 2022;18:e1142-e1149.
The opioid epidemic has prompted national and institutional guidelines for safe opioid prescribing. This paper describes the development, implementation, and sustainment of a toolkit for safer opioid prescribing for chronic pain in primary care. The authors describe organizational, technical, and external barriers to implementation along with attempted solutions and their effects. The toolkit is available as supplemental material.
Klatt TE, Sachs JF, Huang C-C, et al. Jt Comm J Qual Patient Saf. 2021;47:759-767.
… Jt Comm J Qual Patient Saf … This article describes the … of a medical condition, including COVID-19 . … Klatt TE, Sachs JF, Huang CC, et al. Building a program of expanded … the entire health care team:  no one left behind. Jt Comm J Qual Patient Saf. Epub 2021 Sep 29 . …
Mirarchi FL, Cammarata C, Cooney TE, et al. J Patient Saf. 2021;17:458-466.
Prior research found significant confusion among physicians in understanding Physician Orders for Life-Sustaining Treatment (POLST) documents, which can lead to errors. This study found that emergency medical services (EMS) personnel did not exhibit adequate understanding of all POLST or living will documents either. The researchers propose that patient video messaging can increase clarity about treatment, and preserve patient safety and autonomy.
Businger AC, Fuller TE, Schnipper JL, et al. J Am Med Inform Assoc. 2019;27:301-307.
J Am Med Inform Assoc … In 2014, the Agency for Healthcare … real time through EHR integration.   … Businger AC, Fuller TE, Schnipper JL, Rossetti SC, Schnock KO, Rozenblum R, Dalal AK, Benneyan J, Bates DW, Dykes PC. …
Chen Y-F, Armoiry X, Higenbottam C, et al. BMJ Open. 2019;9:e025764.
Patients admitted to the hospital on the weekend have been shown to experience worse outcomes compared to those admitted on weekdays. This weekend effect has been observed numerous times across multiple health care settings. However, whether patient characteristics (patients admitted on the weekend may be more severely ill) or system factors (less staffing and certain services may not be available on the weekend) are primarily responsible remains debated. In this systematic review and meta-analysis including 68 studies, researchers found a pooled odds ratio for weekend mortality of 1.16. Moreover, the weekend effect in these studies was more pronounced for elective rather than unplanned admissions. They conclude that the evidence suggesting that the weekend effect reflects worse quality of care is of low quality. A past PSNet perspective discussed the significance of the weekend effect with regard to cardiology.
Lee W-H, Zhang E, Chiang C-Y, et al. J Patient Saf. 2019;15:61-68.
Trigger tools and incident reporting are widely utilized methods for detecting harm in health care. The most useful method for capturing safety events in the emergency department remains unknown. In this prospective observational study, researchers assessed a monitoring system designed to detect adverse events in the emergency department of an academic medical center over a 1-year period. The system included two event reporting methods and five trigger tools. Of the 285 adverse events identified during the study period, 77.2% were captured by reporting systems, 26% by trigger tools, and 3.2% by both approaches. In keeping with prior research, the authors conclude that the use of a combination of methods for capturing harm is more effective than the use of a singular approach. A past PSNet perspective highlighted the importance of feedback with regard to incident reporting.
Manojlovich M, Frankel RM, Harrod M, et al. BMJ Qual Saf. 2019;28:160-166.
Researchers describe the use of video reflexive ethnography to improve communication between physicians and nurses during rounds at a single academic medical center. They conclude that video reflexive ethnography is feasible and may have the potential to improve communication between physicians and nurses.
Manojlovich M, Hofer TP, Krein SL. J Patient Saf. 2021;17:e732-e737.
… Journal of patient safety … J Patient Saf … Communication problems persistently … between care team members. The authors describe an eight-element framework that targets trust, hierarchy , and technology as an approach to communication improvement that embraces the …
Armato CS, Jenike TE. NEJM Catalyst. May 2, 2018.
… can contribute to medical errors. This article discusses an organizational effort to develop a resilience, wellness, … efforts , such as assigning ownership of the program to an individual and the use of metrics to demonstrate the impact of the program over time. … Armato CS, Jenike TE. NEJM Catalyst. May 2, 2018. … CS … TE … Armato … Jenike … …
Aldridge C, Bion J, Boyal A, et al. Lancet. 2016;388:178-86.
In-hospital mortality for many conditions is higher on the weekends than on weekdays—a phenomenon known as the weekend effect. Some hypothesize lower specialty physician staffing levels on weekends explains the mortality difference. This cross-sectional study compared specialist staffing levels and mortality rates at 115 hospitals in the English National Health Service on Sundays compared to Wednesdays. Researchers found a higher mortality rate and lower intensity of specialty services on weekends, but there was no correlation between the two ratios. Although this study is not definitive, it does imply that alternate mechanisms may explain the weekend effect, such as case mix differences, variation in nonphysician staffing, or lower availability of diagnostic services. A previous PSNet interview discussed the weekend effect in health care.
Alabdali A, Fisher JD, Trivedy C, et al. Air Med J. 2017;36:116-121.
Interfacility transport of critically ill patients may be performed by physician-led teams or by paramedics without direct physician involvement. This systematic review attempted to determine if transport by paramedics alone was safe for patients, but researchers found only a small number of studies with limited characterization of the types of adverse events encountered in this situation.
Manaseki-Holland S, Lilford RJ, Bishop JRB, et al. BMJ Qual Saf. 2017;26:408-416.
Ascertaining whether adverse events are preventable is a continuing challenge in patient safety. Comparing two scales that assess preventability for mortality, this study found that there is high variability among experts rating the preventability of the same mortality event. These results suggest that preventability remains subjective despite attempts to define it in a reproducible fashion.