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
Approach to Improving Safety
Displaying 1 - 20 of 22 Results
Schnipper JL, Reyes Nieva H, Yoon CS, et al. BMJ Qual Saf. 2023;32:457-469.
Implementing successful interventions to support effective medication reconciliation is an ongoing challenge. The MARQUIS2 study examined whether system- and patient-level interventions plus physician mentors can improve medication reconciliation and reduce medication discrepancies. This analysis based on patient exposure in the MARQUIS2 study found that patient receipt of a best possible medication history (BPMH) in the emergency department and medication reconciliation at admission and discharge were associated with the largest reductions in medication discrepancy rates.
Schnipper JL, Reyes Nieva H, Mallouk M, et al. BMJ Qual Saf. 2022;31:278-286.
Medication reconciliation aims to prevent adverse events during transitions of care, but implementing effective interventions supporting medication reconciliation has proven challenging. Building upon lessons learned in the MARQUIS1 study, this pragmatic quality improvement study (MARQUIS2) implemented a refined toolkit including system-level and patient-level interventions as well as physician mentors providing remote coaching and in-person site visits. Across 17 hospital sites, the intervention was associated with a significant decrease in unintentional mediation discrepancies over time.
Wick EC, Sehgal NL. JAMA Surg. 2018;153:948-954.
This systematic review of opioid stewardship practices following surgery identified eight intervention studies intended to reduce postsurgical opioid use. Organizational-level interventions such as changing orders in the electronic health record, demonstrated clear reductions in opioid prescribing. Clinician-facing interventions such as development and dissemination of local guidelines also led to reduced opioid prescribing. The authors emphasize the need for more high-quality evidence on opioid stewardship interventions.
Ranji SR, Rennke S, Wachter R. BMJ Qual Saf. 2014;23:773-80.
This narrative review found that while computerized provider order entry combined with clinical decision support systems effectively prevented medication prescribing errors, there was no clear effect on clinical adverse drug event rates. This finding may be due to alert fatigue and other unintended consequences of the technology.
Martinez W, Hickson GB, Miller BM, et al. Acad Med. 2014;89:482-9.
Although physicians generally support disclosing adverse events, they often choose their words carefully when discussing errors with patients. Since few training programs include formal curricula in error disclosure, most residents and medical students learn these skills through direct observation of senior clinicians. This survey of trainees evaluated the effects of negative and positive role models on their attitudes and behaviors regarding error disclosure. Most trainees had observed a harmful medical error, and the majority reported exposure to positive role models. Poor role models were associated with negative trainee attitudes about disclosure and an increased likelihood of trying to evade responsibility for harmful errors. More than one-third of trainees reported nontransparent behavior in response to a harmful medical error they had made. Addressing the importance of role models in shaping clinicians' future behaviors will be important to advancing full disclosure efforts. An AHRQ WebM&M perspective by Dr. Albert Wu discusses the importance of disclosing adverse events.
Bowman C, Neeman N, Sehgal NL. Acad Med. 2013;88:802-10.
Research on safety culture has primarily focused on practicing clinicians and staff. Medical students are an integral part of the clinical team and are increasingly being integrated into safety efforts, but their views on safety culture are not often taken into account. This survey of senior medical students used a modified version of the AHRQ Hospital Survey on Patient Safety Culture to investigate students' perceptions and found that while students generally had positive impressions of teamwork and felt there was adequate supervision, they did not feel comfortable reporting errors and were concerned that errors would be held against them. The results of this study mirror prior research that consistently finds lower perceptions of safety culture among frontline workers compared with management. Authority gradients play a major role in inhibiting students' desire to report safety problems, an issue discussed in an AHRQ WebM&M commentary.
Rennke S, Nguyen OK, Shoeb MH, et al. Ann Intern Med. 2013;158:433-40.
Despite an intense policy focus on preventing readmissions and adverse events after hospital discharge, this systematic review found only limited evidence to support the use of relatively high-intensity approaches to improving transitional care. This AHRQ-funded study was published as part of a special patient safety supplement in the Annals of Internal Medicine.
WebM&M Case March 1, 2012
… University of California San Francisco Medical Center   … Stephanie Rennke, MD … Assistant Clinical Professor of Medicine … J Hosp Med. 2009;4:211-218. [go to PubMed] 12. Rennke S, Kesh S, Neeman N, Sehgal NL. Complementary telephone …
Sehgal NL, Green A, Vidyarthi A, et al. J Hosp Med. 2010;5:234-9.
This study discovered that while nurses and physicians use patient whiteboards differently, they all value its potential for improving teamwork, communication, and patient care. The authors provide a series of recommendations for those adopting whiteboards and advocate for their use as a patient-centered tool.
Sehgal NL, Fox M, Vidyarthi A, et al. J Gen Intern Med. 2008;23:2053-7.
A teamwork training intervention that involved internal medicine residents, pharmacists, and nurses as well as nonclinical staff was successfully implemented at an academic hospital. The intervention focused on developing teamwork skills and communication techniques, based on interactive discussions between providers of different disciplines.
Sehgal NL, Wachter RM. J Hosp Med. 2007;2:366-371.
This survey of nurse leaders at academic medical centers found great variation in the method used to document patients' do-not-resuscitate (DNR) status. Documentation could be found in the paper chart or electronic medical record, by means of a color-coded wristband, or combinations of these sources. Multiple wristband colors were used to indicate DNR status at different hospitals. This lack of standardization has been recognized as a patient safety problem, and resources exist to create standardized wristbands. The authors call for development of national standards for DNR documentation. In the same issue, the authors share an anecdote (see Associated Image link below) of a patient transferred from one acute facility to another with confusion that resulted from his multiple color-coded wristbands.
WebM&M Case February 1, 2007
A parent brings her 18-month-old into the clinic with multiple complaints, including rash, diarrhea, and concern for fracture due to a fall. The child is sent home with a diagnosis of viral syndrome. Later, still concerned about her child's gait, the mother takes her to the ED, where an x-ray reveals a fractured tibia.