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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 30 Results
Shaikh U, Kim JM, Yin SH. Clin Pediatr (Phila). 2023;20:6788.
The American Academy of Pediatrics' Policy Statement, "Preventing Home Medication Administration Errors", called for improving medication safety at home for children with medical complexity. This article describes a toolkit for pediatricians to support implementation focusing on four interventions: establishing practice-based error reporting systems, standardizing medication reconciliation, improving communication, and integrating resources for patients and families. Of particular importance is the use of health literacy-informed, culturally sensitive resources.
Auerbach AD, Astik GJ, O’Leary KJ, et al. J Gen Intern Med. 2023;38:1902-1910.
COVID-19 ushered in new diagnostic challenges and changes in care practices. In this study conducted during the first wave of the pandemic, charts for hospitalized adult patients under investigation (PUI) for COVID-19 were reviewed for potential diagnostic error. Diagnostic errors were identified in 14% of cases; patients with and without diagnostic errors were statistically similar and errors were not associated with pandemic-related change practices.
Patient Safety Primer December 14, 2022

The rapid expansion of telehealth and the variation in implementation of new models of care into medical practice has resulted in emerging concerns regarding patient safety. This primer summarizes these concerns – including diagnostic errors, medication errors, and health equity considerations – as well as telehealth implementation strategies to enhance patient safety.

Patient Safety Primer March 30, 2022

This primer provides a broad overview of three widely used tools for investigating and responding to patient safety events and near misses. Tools covered in this primer are incident reporting systems, Root Cause Analysis (RCA), and Failure Modes and Effects Analysis (FMEA). These tools have been used in high-risk industries and occupations such as aviation, manufacturing, nuclear power, and the military and have been adapted for use in enhancing patient safety in healthcare settings over the past two decades.

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. 
Patient Safety Primer April 1, 2021

An essential aspect of preventing medical errors and improving patient safety is using data effectively to understand, track and communicate performance on patient safety metrics. This primer provides an overview of visual tools – histograms, scatter plots, run charts and control charts – hospitals and health systems can leverage to track patient safety data.

Raffel KE, Kantor MA, Barish P, et al. BMJ Qual Saf. 2020;29:971-979.
This retrospective cohort study characterized diagnostic errors among adult patients readmitted to the hospital within 7 days of hospital discharge. Over a 12-month period, 5.6% of readmissions were found to contain at least one diagnostic error during the index admissions. These diagnostic errors were primarily related to clinician diagnostic reasoning, including failure to order needed tests, erroneous interpretation of tests, and failure to consider the correct diagnosis. The majority of the diagnostic errors resulted in some form of clinical impact, including short-term morbidity and readmissions.
Perspective on Safety September 1, 2019
… the 20 key resources. Our PSNet clinician editors are Sumant Ranji, Kiran Gupta, Urmimala Sarkar, Audrey Lyndon, and … San Francisco … Sumant … Robert … Ranji … Wachter … R. … Sumant R. Ranji … Robert Wachter …
This piece explores the evolution of PSNet and WebM&M since their inception (WebM&M in 2003 and PSNet in 2005) and summarizes changes in the patient safety landscape over time.
WebM&M Case January 1, 2019
Following urgent catheter-directed thrombolysis to relieve acute limb ischemia caused by thrombosis of her left superficial femoral artery, an elderly woman was admitted to the ICU. While ordering a heparin drip, the resident was unaware that the EHR order set had undergone significant changes and inadvertently ordered too low a heparin dose. Although the pharmacist and bedside nurse noticed the low dose, they assumed the resident selected the dose purposefully.
Sittig DF, Salimi M, Aiyagari R, et al. J Am Med Inform Assoc. 2018;25:913-918.
Although the implementation of health information technology has improved safety, it has also been associated with unintended consequences that can contribute to patient harm. The SAFER Guides were developed to ensure safe implementation of electronic health records across health care systems. However, the extent to which these best practices have been adopted remains unknown. Researchers examined the degree to which 8 organizations adhered to the 140 SAFER recommendations and found that the majority of best practices were not implemented. Across the 8 sites, 25 of the 140 recommendations were fully implemented. A past PSNet perspective discussed the safety of electronic health records.
Shaikh U, Afsar-Manesh N, Amin AN, et al. Int J Qual Health Care. 2017;29:735-739.
Health care institutions are increasingly focused on teaching quality improvement and patient safety to both faculty and trainees. This study describes the implementation of an online course comprised of three quizzes to teach important concepts related to quality improvement, patient safety, and care transitions across five academic medical centers.
Narayana S, Rajkomar A, Harrison JD, et al. J Grad Med Educ. 2017;9:627-633.
Insufficient follow-up with patients after hospitalization hinders identification of diagnostic or treatment errors. This commentary discusses the results of an intervention that incorporated a structured process for residents to gather information and reflect on patient status for postdischarge follow-up.
Duong JA, Jensen TP, Morduchowicz S, et al. J Gen Intern Med. 2017;32:654-659.
Patients hospitalized and cared for by an overnight physician, known as "holdover admissions," are increasingly common due to duty hours limitations, and they necessitate handoffs between admitting physicians and the new primary medical team. This qualitative study identified unmet needs in holdover handoffs, including assessment of diagnostic uncertainty, standardization, and feedback. The authors call for more scrutiny of holdover handoffs.
Perspective on Safety January 1, 2017
A considerable body of evidence demonstrates worsened clinical outcomes for patients admitted to the hospital on weekends compared to those admitted on weekdays. This Annual Perspective summarizes innovative studies published in 2017 that helped clarify the magnitude of this effect and identify possible mechanisms by which it occurs.
A considerable body of evidence demonstrates worsened clinical outcomes for patients admitted to the hospital on weekends compared to those admitted on weekdays. This Annual Perspective summarizes innovative studies published in 2017 that helped clarify the magnitude of this effect and identify possible mechanisms by which it occurs.
Perspective on Safety March 22, 2016
… of preventable deaths in other health care settings. … SumantRanjiR. … Sumant R. Ranji
The toll of medical errors is often expressed in terms of mortality attributable to patient safety problems. In 2016, there was considerable debate regarding the number of patients who die due to medical errors. This Annual Perspective explores the methodological approaches to estimating mortality attributable to preventable adverse events and discusses the benefits and limitations of existing approaches.
Sheu L, Fung K, Mourad M, et al. J Hosp Med. 2015;10:307-10.
Primary care physicians at an academic medical center continued to speak up about concerns regarding the quality of communication they received from inpatient teams even after implementation of a shared electronic medical record. They also expressed a desire for increased direct communication at discharge for complex patients and patients with detailed follow-up needs.
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.