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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 113 Results
Olazo K, Gallagher TH, Sarkar U. J Patient Saf. 2023;19:547-552.
Marginalized patients are more likely to experience adverse events and it is important to encourage effective disclosure to reinforce and reestablish trust between patients and providers. This qualitative study involving clinicians and patient safety professionals explored challenges responding to and disclosing errors involving historically marginalized patients. Participants identified multilevel challenges, including fragmentation of care and patient mistrust as well a desire for disclosure training and culturally appropriate disclosure toolkits to support effective error disclosure.
Rotteau L, Othman D, Dunbar-Yaffe R, et al. BMJ Qual Saf. 2023;Epub Jul 19.
Safety huddles are increasingly used to encourage team communication about safety threats and learning from mistakes. This qualitative study with huddle leaders and participants at five sites found that huddles can enhance engagement in patient safety and identify opportunities for increased support from organizational leadership.
Goldman J, Rotteau L, Flintoft V, et al. BMJ Qual Saf. 2023;32:470-478.
Learning collaboratives within the Canadian Patient Safety Institute are working to implement the Measurement and Monitoring of Safety Framework (MMSF). This paper describes the collaboratives’ experiences with integrating MMSF into their organizations. Hospitals reported small scale success and described challenges with implementation when the Framework was not aligned with existing quality and safety processes.
Doshi S, Shin S, Lapointe-Shaw L, et al. JAMA Intern Med. 2023;183:924-932.
Missed recognition of early signs of clinical deterioration can result in transfer to the intensive care unit (ICU) or death. This study investigated whether critical illness events (transfer to ICU or death) impacted another patient's critical illness event in the subsequent six-hour period. Results suggest one or more critical illness events increase the odds of additional patient transfers into the ICU, but not of death. The authors present several explanations for this phenomenon.
Grenon V, Szymonifka J, Adler-Milstein J, et al. J Patient Saf. 2023;19:211-215.
Large malpractice claims databases are increasingly used as a proxy to assess the frequency and severity of diagnostic errors. More than 5,300 closed claims with at least one diagnostic error were analyzed. No singular factor was identified; instead multiple contributing factors were implicated along the diagnostic pathway.
Wong J, Lee S-Y, Sarkar U, et al. Am J Health Syst Pharm. 2022;79:2230-2243.
Medication errors in ambulatory care settings represent an ongoing patient safety challenge. This study characterizes ambulatory care adverse drug events reported to a large patient safety organization between May 2012 and October 2018. Anticoagulants, antibiotics, hypoglycemics, and opioids were the most commonly involved medication classes. Contributing factors included prescribing errors, failure to review clinical contraindications or drug-drug interactions, and lack of patient education or communication.
Olazo K, Wang K, Sierra M, et al. Jt Comm J Qual Patient Saf. 2022;48:539-548.
Patients and families prefer to be told if they experience a medical error. Given that marginalized patients experience medical errors at higher rates, it is important to understand their unique perspectives and preferences towards error disclosure. This systematic review identified 6 studies focused on error disclosure in one of three marginalized populations (older adults, low education attainment, racial and/or ethnic minority).
Gupta K, Szymonifka J, Rivadeneira NA, et al. Jt Comm J Qual Patient Saf. 2022;48:492-496.
Analysis of closed malpractice claims can be used to identify potential safety hazards in a variety of clinical settings. This analysis of closed emergency department malpractice claims indicates that diagnostic errors dominate, and clinical judgment and documentation categories continue to be associated with a higher likelihood of payout. Subcategories and contributing factors are also discussed.
Fontil V, Khoong EC, Lyles C, et al. Jt Comm J Qual Patient Saf. 2022;48:395-402.
Missed or delayed diagnosis in primary care may result in serious complications for patients. This prospective study followed adults presenting to primary care with new or unresolved symptoms for 12 months. 32% of patients received a diagnosis within one month; most of the rest still did not have a diagnosis at 12 months (50%). The authors suggest interventions aimed at improving diagnosis should be system-based, not specific to a single medical issue or population.
Gupta K, Rivadeneira NA, Lisker S, et al. J Patient Saf. 2022;18:531-538.
Strategies to reduce clinician burnout related to adverse events are critically needed. Physicians in the United States were surveyed on their experiences with adverse events to identify facilitators and barriers to reducing burnout. A common facilitator was peer support, and barriers included shame and a punitive work environment.
Bardach NS, Stotts JR, Fiore DM, et al. J Hosp Med. 2022;17:456-465.
Patients and families represent an often untapped resource in identifying errors and adverse events. Using a mobile health tool, pediatric patients and families were encouraged to report safety events that occurred during the child’s hospital stay. These reports were compared with incident reports (IRs) submitted to the internal incident reporting system. Of the 51 potential IR observations, only one had been submitted to the IR system. Notably, differences in the number of reported events varied by race, ethnicity, insurance status, and other marginalized groups, highlighting a need to explicitly engage these populations. 
Khoong EC, Sharma AE, Gupta K, et al. J Gen Intern Med. 2022;37:1270-1274.
In response to concerns about COVID-19 transmission, many ambulatory care visits have transitioned to telehealth visits. This commentary describes the impact of telehealth on diagnostic errors and medication safety in ambulatory settings. Recommendations to further understand the impact of telemedicine on patient safety include: systematically measuring patient safety outcomes and increasing reporting of safety incidents; identifying the patients and clinical scenarios with the greatest risk of unsafe telehealth care; identifying and supporting best practices to ensure equal access to safe telehealth.
Lo L, Rotteau L, Shojania KG. BMJ Open. 2021;11:e055247.
Situation, Background, Assessment, Recommendation (SBAR) is a mnemonic technique used to avoid communication failures during handoffs. This systematic review found that fidelity with SBAR is highest in classroom settings, but that studies in clinical contexts either did not achieve sufficient improvements in fidelity or did not assess fidelity.
Centola D, Guilbeault D, Sarkar U, et al. Nature Commun. 2021;12:6585.
Race and gender bias in healthcare remains a public health problem. Study participants were assigned to a control (i.e., independent reflection) or intervention (i.e., “egalitarian” information exchange network) group and asked to provide diagnostic and treatment recommendations for standardized patients (a white man or a black woman). Participants in the intervention group were more likely to recommend appropriate care and showed no bias in final recommendations. The authors note that these findings indicate that clinician network interventions might be useful in healthcare settings to reduce disparities in patient treatment.
Sharma AE, Huang B, Del Rosario JB, et al. BMJ Open Qual. 2021;10:e001421.
Patients and caregivers play an essential role in safe ambulatory care. This mixed-methods analysis of ambulatory safety reports identified three themes related to patient and caregivers factors contributing to events – (1) clinical advice conflicting with patient priorities, (2) breakdowns in communication and patient education contributing to medication adverse events, and (3) the fact that patients with disabilities are vulnerable to due to the external environment.  
Khoong EC, Fontil V, Rivadeneira NA, et al. J Am Med Inform Assoc. 2020;28:632-637.
Diagnostic over- and under-confidence in primary care can result in misdiagnosis, impacting millions of patients every year. This intervention study evaluated the effect of peer input on diagnostic confidence on cases with diagnostic uncertainty. In cases with high diagnostic uncertainly, peer input increased provider confidence.