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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 51 Results
Plint AC, Newton AS, Stang A, et al. BMJ Qual Saf. 2022;31:806-817.
While adverse events (AE) in pediatric emergency departments are rare, the majority are considered preventable. This study reports on the proportion of pediatric patients experiencing an AE within 21 days of an emergency department visit, whether the AE may have been preventable, and the type of AE (e.g., management, diagnostic). Results show 3% of children experienced at least one AE, most of which were preventable.
Zerah L, Henrard S, Thevelin S, et al. Age Ageing. 2022;51:afab196.
Adverse drug events (ADEs) are an important cause of hospitalizations in older adults. Based on data from the OPERAM trial, this study explored the accuracy of triggers for identifying medication-related hospital admissions in older adults. Triggers were related to diagnoses (e.g., falls, bleeding, thromboembolic events), laboratory values (e.g., hypo- or hyperglycemia) and other factors (e.g., mention of an ADE in the patient record, abrupt medication discontinuation). Among 1,235 included hospitalizations, 58% cases had at least one trigger; medication-related admissions were adjudicated in 72% of these cases.
Loren DL, Lyerly AD, Lipira L, et al. J Patient Saf Risk Manag. 2021;26:200-206.
Effective communication between patients and providers – including after an adverse event – is essential for patient safety. This qualitative study identified unique challenges experienced by parents and providers when communicating about adverse birth outcomes – high expectations, powerful emotions, rapid change and progression, family involvement, multiple patients and providers involved, and litigious environment. The authors outline strategies recommended by parents and providers to address these challenges.
Berman L, Rialon KL, Mueller CM, et al. J Pediatr Surg. 2021;56:833-838.
Clinicians who are involved in an adverse even often experience emotional and psychological distress afterwards. A survey found that 80% of responding pediatric surgeons had personally experienced a medical error resulting in significant patient harm or death. Only one-quarter of those respondents were satisfied with the institutional support they received afterwards. Respondents cited numerous barriers (lack of trust, blame, shame) to receiving support.    

Halamek LP, ed. Semin Perinatol. 2019;43(8):151172-151182.

The neonatal intensive care unit (NICU) is a complex environment that serves a vulnerable population at increased risk for harm should errors occur. This special issue draws from a multidisciplinary set of authors to explore patient safety issues arising in the NICU. Included in the issue are articles examining topic such as video assessment, diagnostic error, and human factors engineering in the NICU.
Berman L, Ottosen M, Renaud E, et al. J Pediatr Surg. 2019;54:1872-1877.
Morbidity and mortality (M&M) conferences are designed to review adverse events. They are one method by which physicians undergo peer review to evaluate their performance and can allow health systems to identify potential avenues for improving patient safety. A survey of pediatric surgeons found that while the M&M participation was high, few believed the process results in practice changes or preventing future events. M&Ms considered most effective had a structured approach, were data driven with loop closure, emphasized multidisciplinary participation, and served as an educational forum.
Sherman J, Hedli LC, Kristensen-Cabrera AI, et al. Am J Perinatol. 2020;37:638-646.
This direct observation study examined maternal and neonatal care at 10 labor and delivery units. Investigators uncovered three environmental needs that impact safety: rapid access to blood products, space for neonatal resuscitation, and organization and availability of equipment and supplies. They conclude that applying design thinking to physical space could improve maternal and neonatal safety.
Roybal J, Tsao KJ, Rangel S, et al. Pediatr Qual Saf. 2018;3:e108.
Research has shown that the effectiveness of surgical safety checklists in improving patient outcomes is mixed and may depend in part on implementation as well as providers' attitudes toward the importance of such checklists. In this survey study involving pediatric surgeons, 94% reported using surgical safety checklists but just 55% reported that they perceived such checklists to improve safety.

Azar FM, ed. Orthop Clin North Am. 2018;49(4):A1-A8,389-552.

Quality and value have intersecting influence on the safety of health care. Articles in this special issue explore key principles of safe orthopedic care for both adult and pediatric patients. Topics covered include leadership's role in implementing sustainable improvement, postsurgery patient education as a safety tactic, and the impact of surgical volume on safe, high-quality care.
Stockwell DC, Landrigan CP, Toomey SL, et al. Pediatrics. 2018;142:e20173360.
This study used a trigger tool (the Global Assessment of Pediatric Patient Safety) to examine temporal trends in adverse event rates at 16 randomly selected children's hospitals. Adverse event rates did not significantly change at either teaching or nonteaching hospitals from 2007 to 2012. Interestingly, nonteaching hospitals had lower error rates than teaching facilities, although the increased complexity of patients at teaching hospitals may account for this finding. The results of this study mirror those of a similar study conducted in adult hospitals from 2002 to 2007. An accompanying editorial notes that quality improvement collaboratives have achieved reductions in hospital-acquired conditions at children's hospitals and speculates that these discordant findings could be due to the fact that trigger tools are able to detect a broader range of adverse events and thus may provide a more accurate picture of safety. A WebM&M commentary discussed a preventable medication error at a children's hospital.
Schnock KO, Dykes PC, Albert J, et al. Drug Saf. 2018;41:591-602.
Intravenous medication administration errors related to smart pumps can compromise patient safety. Prior research has shown that such errors are common and often involve incorrect dosing and workarounds. Researchers describe the development and implementation of a multicomponent safety intervention bundle developed to reduce medication administration errors associated with smart pump use. Although both the overall error rate and medication error rate per 100 medication administrations decreased, the intervention did not lead to a reduction in the rate of potentially harmful errors. A past PSNet perspective discussed the use of smart pumps to improve safety.
Gleason KT, Davidson PM, Tanner EK, et al. Diagnosis (Berl). 2017;4:201-210.
In light of recent expert analysis and improvement work, the concept of treating diagnosis as team activity is gaining acceptance. This review describes a framework for engaging nurses in the diagnostic process to enhance multidisciplinary teamwork and patient involvement. The authors suggest improvements in health care culture is required to implement the recommended changes, which include a focus on creating opportunities for shifting the process to be more patient centered.
Hirata KM, Kang AH, Ramirez G, et al. Pediatr Emerg Care. 2019;35:637-642.
Weight-based dosing errors can lead to adverse drug events. This retrospective study found that weight-related errors are rare but did lead to medication dosing errors and potential for harm. This finding underscores the need to address weight-based dosing on a systems level.
Pitts SI, Maruthur NM, Luu N-P, et al. Jt Comm J Qual Saf. 2017;43:591-597.
Comprehensive unit-based safety programs have been shown to enhance safety in acute care settings. The investigators adapted this program for a primary care setting and report that safety culture improved following implementation of standard work and safety training. The authors did not report on patient outcomes.
Helmchen LA, Lambert BL, McDonald TB. Health Serv Res. 2016;51:2516-2536.
Programs to disclose errors and offer compensation, known as communication-and-resolution programs, have been shown to reduce malpractice claims. This pre–post study found that the growth of diagnostic testing for chest pain slowed after implementation of a communication-and-resolution program. The authors suggest further study to determine whether these results represent an appropriate reduction in unnecessary testing.
Thorpe JM, Thorpe CT, Gellad WF, et al. Ann Intern Med. 2017;166:157-163.
Prior research suggests that polypharmacy in patients with dementia may increase the risk of functional decline. This retrospective cohort study found that veterans with dementia who sought care from both within the Department of Veterans Affairs (VA) and from other health systems were more likely to receive prescriptions for potentially unsafe medications than those who sought care only within the VA system.
Lambert BL, Centomani NM, Smith KM, et al. Health Serv Res. 2016;51:2491-2515.
Research has demonstrated that disclosing errors to patients results in fewer malpractice claims, but such discussions do not always take place. This observational study described the effect of implementing the AHRQ Communication and Optimal Resolution (CANDOR) toolkit, an intervention bundle intended to support error disclosure, at a single health system. The investigators found that incident reports increased, suggesting that more safety problems were identified and reported. Also, the number of malpractice claims, along with their resultant costs, decreased significantly. Using an interrupted time series design, they established that these outcomes persisted more than 7 years after the program was introduced. The authors suggest that such programs can result in significant cost savings to health systems. A past PSNet perspective discussed error disclosure in health care.
Toomey SL, Peltz A, Loren S, et al. Pediatrics. 2016;138.
Readmissions to the hospital are considered a marker of patient safety, and hospitals with high readmission rates are subject to reduced Medicare reimbursements. The extent to which readmissions are preventable remains controversial. Investigators examined 300 pediatric readmissions at a single hospital with input from inpatient providers, primary care providers, patients, family members, and medical records. They determined that approximately 30% of readmissions were preventable. Both patient-related factors such as parental anxiety and hospital-related factors such as hospital-acquired conditions contributed to preventable readmissions. The authors emphasize the importance of interviewing patients and family members as well as medical providers to better characterize the preventability of readmissions. They suggest that identifying factors associated with preventable readmissions will lead to readmission reduction strategies. Multiple strategies targeting the different contributing factors will likely be needed. A past PSNet interview reflected on the challenge of preventing readmissions.