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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 - 18 of 18 Results
Ivanovic V, Broadhead K, Beck R, et al. AJR Am J Roentgenol. 2023;221:355-362.
Like many clinical areas, a variety of system factors can influence diagnostic error rates in neuroradiology. This study included 564 neuroradiologic examinations with diagnostic error and 1,019 without error. Diagnostic errors were associated with longer interpretation times, higher shift volume, and weekend interpretation.
Ivanovic V, Assadsangabi R, Hacein-Bey L, et al. Clin Radiol. 2022;77:607-612.
Radiological interpretation errors can result in unnecessary additional tests, wrong treatment and delayed diagnosis. This study explored the correlation between neuroradiologists’ diagnostic errors and attendance at institutional tumor boards. Results show that higher attendance at tumor boards was strongly correlated with lower diagnostic error rates. The researchers recommend increased and continuous attendance at tumor boards for all neuroradiologists.
Liang C, Miao Q, Kang H, et al. Stud Health Technol Inform. 2019;264:983-987.
This AHRQ-funded analysis of patient safety research found that research output—as measured by federal grant funding and peer-reviewed publications—increased sharply between 1995 and 2014. Publication of the To Err Is Human report and passage of federal budget stimulus funds were associated with an increase in patient safety publications and research funding.
Chen Q, Rosen AK, Amirfarzan H, et al. Am J Surg. 2018;216:846-850.
In this study, researchers analyzed 245 intraoperative errors and adverse events reported by physicians through both surgical debriefings and the hospital's incident reporting system. They found a positive association between the presence of intraoperative events and increased postoperative morbidity for patients. In keeping with prior research, the authors conclude that using multiple sources of data provided a more comprehensive picture of safety during surgery.
Cornes M, Ibarz M, Ivanov H, et al. Diagnosis (Berl). 2019;6:33-37.
Common blood sample errors, such as mislabeling or patient misidentification, can contribute to diagnostic delays. This review highlights the importance of using open-ended questions to gather information from patients and suggests that specimens be labeled with the patient present to ensure accurate verification. A WebM&M commentary explored problems associated with mislabeled blood samples.
Bejnordi BE, Veta M, van Diest PJ, et al. JAMA. 2017;318:2199-2210.
Diagnostic error is a growing area of focus within patient safety. Artificial intelligence has the potential to improve the diagnostic process, both in terms of accuracy and efficiency. In this study, investigators compared the use of automated deep learning algorithms for detecting metastatic disease in stained tissue sections of lymph nodes of women with breast cancer to pathologists' diagnoses. The algorithms were developed by researchers as part of a competition and their performance was assessed on a test set of 129 slides, 49 with metastatic disease and 80 without. A panel of 11 pathologists evaluated the same slides with a 2-hour time limit and one pathologist evaluated the slides without any time constraints. The authors conclude that some of the algorithms demonstrated better diagnostic performance than the pathologists did, but they suggest that further testing in a clinical setting is warranted. An accompanying editorial discusses the potential of artificial intelligence in health care.
Chen Q, Rosen AK, Borzecki A, et al. Health Serv Res. 2016;51:2140-2157.
The AHRQ Patient Safety Indicators (PSIs) use hospitals' administrative data to measure quality and carry financial consequences for hospitals as part of pay-for-performance initiatives. Prior research has raised concerns about the validity of PSIs compared with directly using clinical data to identify safety events. AHRQ recently restructured PSI-90 (a composite measure containing multiple distinct PSIs) from volume-based to harm-based weighting. Using data from 132 Veterans Health Administration hospitals, this retrospective study compared hospital performance using the previous PSI-90 with performance under the redesigned measure. Although there was strong association between the volume-based and harm-based PSI-90 measures, use of the harm-based version had a significant impact on pay-for-performance because of changes in the weights of the component measures. Approximately 15% of hospitals in the study would face changes in financial penalties under the Hospital-Acquired Condition Reduction Program when using the new PSI-90. A past PSNet perspective discussed the impact of pay-for-performance.
Govindarajan A, Urbach DR, Kumar M, et al. N Engl J Med. 2015;373:845-53.
The link between lack of sleep and subsequent medical errors served as an impetus for physician duty-hours reform. In trainee physicians, sleep loss is associated with attentional failures, but little is known about the relationship between attending physician performance and sleep loss. This retrospective cohort study examined outcomes of elective surgical procedures among attending surgeons who had worked after midnight on the previous night versus those who had not. The investigators found no differences in mortality, complications, or readmissions between procedures performed by surgeons with sleep loss compared to those without sleep loss, mirroring results of an earlier simulation study. This may be due to greater technical skill among attending surgeons, or the ability to cancel or postpone elective procedures as needed at times of fatigue. This study included many institutions, physicians, and procedure types, suggesting that short-term sleep deprivation might not be a high-yield safety target for attending surgeons.
Schwartzberg D, Ivanovic S, Patel S, et al. J Surg Res. 2015;198:108-14.
This pre-post study found an increase in medication prescribing errors following the introduction of computerized provider order entry. This work adds to the growing literature about unintended consequences of electronic prescribing, highlighting the need for real-time error detection.
Chen Q, Shin MH, Chan J, et al. Am J Med Qual. 2016;31:178-86.
This study reports the development of a comprehensive patient safety tool for Veterans Administration medical centers, with input from frontline stakeholders, to integrate data sources including incident reports, AHRQ Patient Safety Indicators, and other quality measures related to safety in a single location in order to facilitate collaboration at local sites.
Mull HJ, Borzecki A, Loveland S, et al. Am J Surg. 2014;207:584-95.
There is consensus that multiple methods must be used in order to detect adverse events during hospitalization. This study found that the AHRQ Patient Safety Indicators had poor sensitivity for identifying preventable harm in surgical patients when compared directly to the National Surgical Quality Improvement Program methodology.
Rosen AK, Chen Q, Borzecki A, et al. Health Serv Res. 2014;49:1426-45.
This retrospective study of hospital data found that estimated adverse event rates varied between use of AHRQ Patient Safety Indicators and chart abstraction. These differences translated into substantial changes in hospital performance ratings and payments, emphasizing the challenge in using administrative data to assess hospital safety.
Mull HJ, Borzecki A, Chen Q, et al. Am J Med Qual. 2014;29:213-9.
The AHRQ Patient Safety Indicators (PSIs) have traditionally been used to detect adverse events during hospitalization. However, in this study the PSIs were able to identify adverse events after discharge in patients who did not experience preventable harm while hospitalized. As readmission rates are proving to be a problematic measure of discharge safety, screening for adverse events may more reliably assess care transitions' effectiveness.
Rosen AK, Loveland S, Shin MH, et al. Med Care. 2013;51:37-44.
Patients who experience a preventable adverse event while hospitalized may experience prolonged hospitalizations and excess morbidity and mortality. However, as this study demonstrates, the deleterious effects of experiencing a medical error may extend after hospitalization. Examining data from the Veterans Affairs system, researchers found that the risk of readmission within 30 days after discharge increased by 22% if an adverse event (measured by the AHRQ Patient Safety Indicators) occurred during the index hospitalization. This finding corroborates a prior study in surgical patients. Although it is difficult to predict readmission risk in an individual patient, this study indicates that preventable adverse events may be considered a risk factor for readmission.
Wang C, Hefflin B, Cope JU, et al. Pediatrics. 2010;126:247-59.
This study found that contact lenses were responsible for 23% of medical device–associated adverse events requiring an emergency department visit. The authors provide additional detailed analyses, including the most frequently affected body parts and age distribution for device-related events.