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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 141 Results
Hilario C, Louie-Poon S, Taylor M, et al. Int J Soc Determinants Health Health Serv. 2023;53:343-353.
Structural racism is increasingly recognized as a social determinant of health. This systematic review identified 13 articles on the impact of racism on racialized adolescents. Most articles focused on the impact of racism on healthcare access and utilization, and in general or mental health care. Research into multiple forms of racism (i.e., institutional, interpersonal, internalized) and development and incorporation of robust measures of racism is needed to advance the field.
Aiken LH, Lasater KB, Sloane DM, et al. JAMA Health Forum. 2023;4:e231809.
While the association between clinician burnout and patient safety are not new, the COVID-19 pandemic brought this safety concern back to the forefront. In this study conducted at 60 US Magnet hospitals, nurses and physicians reported high levels of burnout and rated their hospital unfavorably on patient safety. Increased nurse staffing was the top recommendation to reduce burnout with less emphasis on wellness and resilience programs.
Ames SG, Delaney RK, Houtrow AJ, et al. Pediatrics. 2023;152:e2022060975.
People with disabilities encounter a variety of system- and clinician-level barriers when seeking healthcare. This study reports on disability-based discrimination faced by children with medical complexities and their caregivers. Apathy, clinician assumptions, and lack of clinician knowledge were identified as drivers of discrimination resulting in limited accessibility, substandard care, and dehumanization.
Murphy DR, Zimolzak AJ, Upadhyay DK, et al. J Am Med Inform Assoc. 2023;30:1526-1531.
Measuring diagnostic performance is essential to identifying opportunities for improvement. In this study, researchers developed and evaluated two electronic clinical quality measures (eCQMs) to assess the quality of colorectal and lung cancer diagnosis. Each measure used data from the electronic health record (EHR) to identify abnormal test results, evidence of appropriate follow-up, and exclusions that signified unnecessary follow-up. The authors describe the measure testing results and outline the challenges in working with unstructured EHR data.
Kennedy GAL, Pedram S, Sanzone S. Safety Sci. 2023;165:106200.
Simulation training is an important component of medical education. In this study, researchers compared the impact of traditional clinical skills training with or without interactive virtual reality (VR) on human error among medical students performing arterial blood gas collection. Findings indicate that students who participated in VR-based clinical skills training were less likely to commit errors during simulated practical exam compared to students who did not participate in VR-based training.

Kennedy-Moulton K, Miller S, Persson P, et al. Cambridge, MA: National Bureau of Economic Research; 2022. NBER Working Paper No. 30693.

Unequal maternal care access and safety are known problems in communities of color. This report examines the alignment of economic stability with maternal and infant care quality and found parental income secondary to race and ethnicity as a damaging influence on care outcomes.
Gleeson LL, Clyne B, Barlow JW, et al. Int J Pharm Pract. 2023;30:495-506.
Remote delivery of care, such as telehealth and e-prescribing, increased sharply at the beginning of the COVID-19 pandemic. This rapid review was conducted to determine the types and frequency of medication safety incidents associated with remote delivery of primary care prior to the pandemic. Fifteen articles were identified covering medication safety and e-prescribing; none of these studies associated medication safety and telehealth.
Baldwin CA, Hanrahan K, Edmonds SW, et al. Jt Comm J Qual Patient Saf. 2023;49:14-25.
Unprofessional and disruptive behavior can erode patient safety and safety culture. The Co-Worker Observation System (CORS), a peer-to-peer feedback program previously used with physicians and advance practice providers, was implemented for use with nurses in three hospitals. Reports of unprofessional behavior submitted to the internal reporting system were evaluated by the CORS team, and peer-to-peer feedback was given to the recipient. This pilot study demonstrated that the implementation bundle can be successful with nursing staff.
Thevelin S, Pétein C, Metry B, et al. BMJ Qual Saf. 2022;31:888-898.
Polypharmacy can place older adults at increased risk of adverse drug events. This mixed-methods study, embedded in the OPERAM trial, identified differences in perceived shared decision-making regarding medication changes between providers and older adult patients. Whereas clinicians reported high levels of shared decision-making, patients reported poor communication and paternalistic decision-making.
McKay C, Schenkat D, Murphy K, et al. Hosp Pharm. 2022;57:689-696.
Insulin is a high-alert medication due to heightened risk for serious patient harm if administered incorrectly. This review presents types of common errors (e.g., wrong patient, cross-contamination), pros and cons of potential dispensing strategies, and the impact of organizational factors (e.g., workflows, cost) on safe dispensing. Additionally, the authors make recommendations for dispensing, taking organization factors into account.

Zimolzak AJ, Singh H, Murphy DR, et al. BMJ Health Care Inform. 2022;29(1):e100565.

Patient safety algorithms developed through research must also be implemented into clinical practice. This article describes the process of translating an electronic health record-based algorithm for detecting missed follow-up of colorectal or lung cancer testing, from research into practice. All 12 test sites were able to successfully implement the trigger and identify appropriate cases.
Yeh JC, Chae SG, Kennedy PJ, et al. J Pain Symptom Manage. 2022;64:e133-e138.
Potentially inappropriate opioid infusion use can result in adverse patient outcomes. This single-site retrospective study found that potentially inappropriate opioid infusions are prevalent (44% of patients receiving opioid infusions during end-of-life care) and were associated with high rates of patient and staff distress.
Estiri H, Strasser ZH, Rashidian S, et al. J Am Med Inform Assoc. 2022;29:1334–1341.
While artificial intelligence (AI) in healthcare may potentially improve some areas of patient care, its overall safety depends, in part, on the algorithms used to train it. One hospital developed four AI models at the start of the COVID-19 pandemic to predict risks such as hospitalization or ICU admission. Researchers found inconsistent instances of model-level bias and recommend a holistic approach to search for unrecognized bias in health AI.
Paterson EP, Manning KB, Schmidt MD, et al. J Emerg Nurs. 2022;48:319-327.
Automated dispensing cabinets (ADCs) can reduce medication dispensing errors by requiring pharmacist verification. This study found that medication overrides (i.e., bypassing pharmacist review before administration) in one pediatric emergency department were frequently not due to an emergent situation requiring immediate medication administration and could have been avoided.
McDonald EG, Wu PE, Rashidi B, et al. JAMA Intern Med. 2022;182:265-273.
Deprescribing is one intervention to reduce the risk of adverse drug events, particularly in older adults and people taking five or more medications. In this cluster randomized trial, older adults (≥65 years) taking at least five medications at hospital admission were randomly assigned to intervention (personalized reports of deprescribing opportunities) or control. Despite an increase in deprescribing in both groups, there was no difference in adverse drug events or adverse drug withdrawal events.
Hegarty J, Flaherty SJ, Saab MM, et al. J Patient Saf. 2021;17:e1247-e1254.
Defining and measuring patient safety is an ongoing challenge. This systematic review explored international approaches to defining serious reportable patient safety incidents. Findings indicate wide variation in terminology and reporting systems among countries which may contribute to missed opportunities for learning. Serious reportable patient safety events were commonly defined as being largely preventable; having the potential for significant learning; causing serious harm or having the potential to cause serious harm; measurable and feasible to report, and; running the risk of recurrence.
Dunbar NM, Delaney M, Murphy MF, et al. Transfusion (Paris). 2021;61:2601-2610.
Transfusion errors can have serious consequences. This study compared wrong blood in tube (WBIT) errors in 9 countries across three settings: emergency department, inpatient, and outpatient. Results show emergency department WBIT errors were significantly higher in emergency departments, and that electronic positive patient identification (ePPID) significantly reduced WBIT errors in the emergency department, but not in inpatient or outpatient wards.
Blum MR, Sallevelt B, Spinewine A, et al. BMJ. 2021;374:n1585.
Older adults with multimorbidity and polypharmacy are at increased risk of adverse drug events. This cluster randomized controlled trial compared drug-related hospitalization rates of older adults who received a structured deprescribing intervention and those who received usual care. While rates of polypharmacy decreased, there was no effect on drug-related hospitalizations.