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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 78 Results
Gandhi TK, Schulson LB, Thomas AD. Jt Comm J Qual Patient Saf. 2023;Epub Sept 12.
Safety event reporting from both providers and patients is subject to bias. The authors of this commentary present several ways bias is introduced into reporting and offers strategies to ensure events are reported and analyzed in an equitable manner.
Gandhi TK. Jt Comm J Qual Patient Saf. 2023;49:235-236.
Safety event reporting is a primary method of gathering data to enhance learning from error. This commentary suggests that a broader approach is needed by engaging patients and gathering their perception of safety to provide a full picture of gaps in care that could result in harm.
Gandhi TK. Jt Comm J Qual Patient Saf. 2022;48:61-64.
Families and caregivers play an important role in ensuring patient safety. At the start of the COVID-19 pandemic and, to a lesser extent, during surges, family and caregiver visitation was severely restricted. This commentary advocates reassessing risks and benefits of restricted visitation, both during the pandemic and beyond.
Li L, Foer D, Hallisey RK, et al. J Patient Saf. 2022;18:e108-e114.
Despite the introduction of computerized provider order entry into electronic health records, providers still frequently use free-text fields to communicate important information which introduces a patient safety risk. One healthcare system searched allergy-related free-text fields, identifying more than 242,000 entries. Approximately 131,000 were manually or automatically remediated (e.g., “latex from back brace” and “gloves” were coded “latex-natural rubber”).
Gandhi TK, Singh H. J. Hosp Med. 2020;15:363-366.
The authors present a nomenclature to describe eight types of diagnostic errors anticipated in the COVID-19 pandemic (classic, anomalous, anchor, secondary, acute collateral, chronic collateral, strain and unintended diagnostic errors) and highlight mitigation strategies to reduce potentially preventable harm, including the use of electronic decision support, communication tactics such as visual aids, and huddles. Organizational strategies (e.g., peer-support, duty hour limits, and forums for transparent communication) and state/federal guidance around testing and monitoring diagnostic performance are also discussed.
Franklin BJ, Gandhi TK, Bates DW, et al. BMJ Qual Saf. 2020;29:844–853.
Huddles are one technique to enhance team communication, identify safety concerns and built a culture of safety. This systematic review synthesized 24 studies examining the impact of either unit-based or hospital-wide/multiunit safety huddles. The majority of studies were uncontrolled pre-post study designs; only two studies were controlled and quantitatively measured intervention adoption and fidelity. Results for unit-based huddle programs appear positive. Given the limited number of studies evaluating hospital-wide huddle programs, the authors conclude that there is insufficient evidence to assess the benefit. Further research employing strong methodological designs is required to definitively assess the impact of huddle programs.
Gandhi TK, Feeley D, Schummers D. NEJM Catalyst. 2020;1.
Health systems are encouraged to strive for zero preventable harm, but achieving this goal requires a comprehensive, systems-focused effort. This paper discusses the rationale for using ‘zero harm’ as a patient safety goal, and the importance of broadening the definition of harm to include non-physical harms (e.g., psychological harms), harms to caregivers and the healthcare workforce, and harms occurring beyond the hospital and across the care continuum. Four key elements required for successful systems change resulting in safety improvements are discussed: (1) change management, (2) culture of safety, (3) a learning system, and (4) patient engagement and codesign of healthcare.
Zuccotti G, Samal L, Maloney FL, et al. Ann Intern Med. 2018;168:820-821.
Failure to follow up abnormal test results can lead to a delayed or missed diagnosis. Using data from a single institution, researchers observed that while more than 99% of abnormal mammograms received appropriate follow-up, only 91% of abnormal Papanicolaou (Pap) smears did. They suggest that improving workflow processes and ensuring appropriate use of health information technology can help optimize test result follow-up.
McGaffigan PA, Ullem BD, Gandhi TK. Jt Comm J Qual Patient Saf. 2017;43:267-274.
Board and leadership engagement is considered critical for advancing patient safety. In this survey study, safety and quality leaders rated board and executive leaders as less engaged in patient safety and quality compared to executive and board member self-perceptions. These findings suggest room for enhanced executive engagement.
Tsou AY, Lehmann CU, Michel J, et al. Appl Clin Inform. 2017;8:12-34.
The copy-and-paste phenomenon represents one of the unintended consequences of electronic health record implementation and may introduce risks to patient care. The authors of this systematic review concluded that though copying and pasting information is common, the evidence supporting an adverse impact on patient safety remains limited.
Gandhi TK. N Engl J Med. 2016;375:1705-1707.
System failures can remain undetected over time in large organizations. This perspective describes elements of a health care research environment that enabled lapses in safety, such as financial pressures and shifting priorities. The author calls for industry-wide learning from this example to ensure that patient safety remains a priority and that organizations invest and commit to an infrastructure that encourages safety.
Hamedani A, Safdar B, Aaronson E, et al. Ann Intern Med. 2016;165:869-870.
Patient safety leaders have long advocated for research to focus on how systems contribute to medical error. This commentary spotlights the need to apply the systems approach to enhance patient experience and suggests that doing so might improve physician engagement and help address burnout.
Bell SP, Schnipper JL, Goggins K, et al. J Gen Intern Med. 2016;31:470-477.
This randomized controlled trial at two academic medical centers studied the potential benefits of providing pharmacist medication reconciliation and counseling, along with individualized telephone follow-up after discharge, for adult patients hospitalized with acute coronary syndrome or acute decompensated heart failure. This extensive intervention did not reduce readmissions or emergency department visits within 30 days of discharge, though there was a small positive effect seen in patients with low health literacy.
Overhage JM, Gandhi TK, Hope C, et al. J Patient Saf. 2016;12:69-74.
Adverse drug events (ADEs) are a common source of patient harm in the ambulatory setting. A substantial proportion of ADEs are caused by preventable errors in medication prescribing or monitoring. The introduction of computerized provider order entry (CPOE) has been shown to reduce the rate of medical errors in the inpatient setting. This before–after study examined rates of ADEs in primary care practices that implemented a CPOE system in Boston and Indianapolis. At baseline, the potential ADE rate was more than seven-fold greater in Indianapolis compared to Boston. Following CPOE implementation, this rate decreased by 56% in Indianapolis but increased by 104% in Boston, and there was no change overall in preventable ADEs. A recent PSNet annual perspective reviewed the relationship and current evidence linking CPOE and patient safety.
Gandhi TK, Berwick DM, Shojania KG. JAMA. 2016;315:1829-30.
This commentary discusses findings from the National Patient Safety Foundation report investigating the state of patient safety in the 15 years after To Err Is Human. Focusing on the recommendation that leadership establish and sustain a culture of safety, the authors describe how leaders can engage board members and organizational leadership in this work and highlight the need to provide leaders with education and practical tools.
Leung AA, Denham CR, Gandhi TK, et al. J Patient Saf. 2015;11:89-99.
Barcode technology has been advocated as a strategy to reduce medication errors. This narrative review explored barcoding solutions applied in various care settings and found that they resulted in notable reductions of transcription, dispensing, and administration errors. The authors recommend standards for successful implementation of barcode technology systems.
McTiernan P, Wachter R, Meyer GS, et al. BMJ Qual Saf. 2015;24:162-6.
Past commentaries have explored the tension between balancing no blame and individual accountability for medical errors. This commentary summarizes a debate exploring accountability in patient safety, with one argument describing the need for health care to differentiate individual failures from systems problems and an opposing perspective suggesting that incorporating blame would hinder progress in patient safety.