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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 36 Results
Gifford A, Butcher B, Chima RS, et al. J Hosp Med. 2023;Epub Oct 4.
Shared situation awareness is shown to improve patient outcomes in the pediatric intensive care unit (PICU). This article outlines the process of designing communication and signage tools to maintain or improve situational awareness in anticipation of moving to a new clinical space. With the new tools in place in the new PICU, shared situation awareness for residents, nurses, and respiratory therapists improved.
Sosa T, Galligan MM, Brady PW. J Hosp Med. 2022;17:199-202.
J Hosp Med … Situation awareness supports effective teamwork … through situation awareness. … Sosa T, Galligan MM, Brady PW. Clinical progress note: situation awareness for clinical deterioration in hospitalized children. J Hosp Med. 2022;17(3):199-202. doi: 10.1002/jhm.2774 …
Yin HS, Neuspiel DR, Paul IM, et al. Pediatrics. 2021;148:e2021054666.
Children with complex home care needs are vulnerable to medication errors. This guideline suggests strategies to enhance medication safety at home that include focusing on health literacy, prescriber actions, dosing tool appropriateness, communication, and training of caregivers. 
Sosa T, Mayer B, Chakkalakkal B, et al. Hosp Pediatr. 2022;12:37-46.
Many medications and medical devices can result in preventable harm in pediatric patients. This article describes one hospital’s efforts to implement explicit, structured processes and huddles to increase situational awareness regarding high-risk therapies among the care team and family members. After implementation, the percentage of electronic health record (EHR) alerts correctly describing high-risk therapies increased from 11% to 96%.
Sosa T, Sitterding M, Dewan M, et al. Pediatrics. 2021;148:e2020034603.
Situational awareness during critical incidents is a key attribute of effective teams. This article describes the development of a situational awareness model, which included involving families and the interdisciplinary team in huddles, a shared mental model checklist, and an electronic health record (EHR) situational awareness navigator. Use of this new model decreased emergency transfers to the ICU and improved process measures, such as improved risk recognition before medical response team activation.
Uong A, Philips K, Hametz P, et al. Pediatrics. 2021;147:e20200031.
Breakdowns in communication between clinicians and patients and their caregivers are common and can lead to adverse events. This article describes the development of the SAFER Care framework for written and verbal discharge counseling in pediatric units. The SAFER mnemonic reminds clinicians delivering discharge counseling to discuss safe return to school/daycare, activity restrictions, follow-up plans expected symptoms after discharge, when to return and seek care for symptoms, and who to contact with questions. Results from caregiver surveys indicate that the SAFER Care framework improved their comprehension of discharge instructions.
Ipsaro AJ, Patel SJ, Warner DC, et al. Hosp Pediatr. 2021;11:334-341.
Understanding physician communication regarding diagnostic uncertainty is an important component of reducing diagnostic error. This article outlines a process for identifying pediatric inpatients with uncertain diagnoses and improving shared recognition among interdisciplinary health care teams.
Dadlez NM, Adelman JS, Bundy DG, et al. Ped Qual Saf. 2020;5:e299-e305.
Diagnostic errors, including missed diagnoses of adolescent depression, elevated blood pressure, and delayed response to abnormal lab results, are common in pediatric primary care. Building upon previous work, this study used root cause analyses to identify the failure points and contributing factors to these errors. Omitted process steps included failure to screen for adolescent depression, failure to recognize and act on abnormal blood pressure values, and failure to notify families of abnormal lab results. Factors contributing most commonly to these errors were patient volume, inadequate staffing, clinic environment, electronic and written communication, and provider knowledge.
Sump CA, Marshall TL, Ipsaro AJ, et al. Diagnosis. 2021;8:353-357.
Diagnostic uncertainty has been described as a clinician perception that affects diagnostic evaluation and can lead to diagnostic errors and negative patient outcomes. This single site cross-sectional study describes the clinical characteristics and healthcare utilization among pediatric patients prospectively identified as having an ‘uncertain diagnosis’ (defined as patients with high likelihood to have a different diagnosis resulting in a change in management). Of the 200 patients meeting inclusion criteria, 45% had gastrointestinal symptoms (e.g., vomiting, abdominal pain, diarrhea). Five percent of patients (5%) required a rapid response team and 3.5% were transferred to intensive care. The authors suggest that better methods to prospectively identify patients with an ‘uncertain diagnosis’ can result in optimized care for these patients.
Bundy DG, Singh H, Stein RE, et al. Clin Trials. 2019;16:154-164.
Diagnostic errors in pediatric primary care are common and represent an ongoing patient safety challenge. In this stepped-wedge, cluster-randomized trial, researchers were able to successfully recruit a diverse group of pediatric primary care practices to participate in virtual quality improvement collaboratives designed to reduce diagnostic error.
Modi A, Germain E, Soma V, et al. Jt Comm J Qual Patient Saf. 2018;44:599-604.
Pediatric patients are at particularly high risk for medication errors. This retrospective review of voluntary error reports of pediatric antibiotic errors found that less than 15% reached the patient and 1.5% caused harm. The risk varied by medication class, and authors suggest developing quality improvement initiatives focused on the highest risk medications.
Rinke ML, Singh H, Heo M, et al. Acad Peds. 2018;18:220-227.
In the Improving Diagnosis in Health Care report, the National Academy of Medicine proclaimed that diagnostic errors are common, cause substantial morbidity, and are understudied. This report has led to multidisciplinary efforts to measure diagnostic error rates in both ambulatory and inpatient settings. This study examined the prevalence of three diagnostic errors in pediatric primary care practices. They found that diagnostic errors were common. Providers did not follow up abnormal laboratory values for 11% of patients and did not address adolescent depression in 62% of visits. These high rates are similar to those found in other practice settings. The authors discuss an ongoing quality improvement collaborative working to reduce diagnostic errors in pediatric primary care practices. Previous WebM&M commentaries highlight cognitive and system-level interventions to prevent diagnostic errors.
Dadlez NM, Azzarone G, Sinnett MJ, et al. Hosp Pediatr. 2017;7:134-139.
Interruptions are known to contribute to medication errors. This direct observation study found that resident physicians and physician assistants experienced 57 interruptions per 100 medication orders. The authors suggest that inpatient health systems should implement strategies to reduce interruptions during medication ordering.
Rinke ML, Singh H, Ruberman S, et al. Diagnosis (Berl). 2016;3:65-69.
The frequency of diagnostic errors in outpatient care remains unclear. In this survey of outpatient general pediatricians, about one-third reported making a diagnostic error every month. This finding underscores the importance of enhancing the safety of diagnosis in ambulatory settings.