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 2493 Results

"We're not taken seriously": describing the experiences of perceived discrimination in medical settings for Black women.

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Washington A, Randall J. J Racial Ethn Health Disparities. 2023;10:883-891.

Discrimination can contribute to health inequities and exacerbate disparities in cancer care. In this study, researchers used a survey tool and qualitative interviews to explore the experiences of perceived discrimination for Black women and how it impacts cervical cancer prevention. Study findings suggest that perceived high degrees of discrimination create mistrust between patients and providers and can impact health outcomes.

Which adverse events and which drugs are implicated in drug-related hospital admissions? A systematic review and meta-analysis.

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Haerdtlein A, Debold E, Rottenkolber M, et al. J Clin Med. 2023;12:1320.

Adverse drug events (ADE) can result in patient harm, hospital admissions, and, in severe cases, death. This systematic review and meta-analysis estimates the prevalence of preventable ADEs resulting in emergency department visits or hospitalization, and the types and prevalence of ADEs and implicated drugs.

Society for Maternal-Fetal Medicine Special Statement: curriculum outline on patient safety and quality for maternal-fetal medicine fellows.

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Am J Obstet Gynecol. 2023;Epub Feb 2.

Efforts to embed patient safety content into defined post-graduate medical curriculum face challenges due to time, culture, and program resource demands. This statement provides detailed safety and quality content recommendations for maternal-fetal medicine fellows that focus on topics such as safety culture, event reporting, and disparities.

Duplicate Therapies in Retail Pharmacy

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WebM&M Case March 15, 2023

The cases described in this WebM&M reflect fragmented care with lapses in coordination and communication as well as failure to appropriately address medication discrepancies. These two cases involve duplicate therapy errors, which have the potential to cause serious adverse drug events.

Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists

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WebM&M Case March 15, 2023

A 71-year-old man presented to his physician with rectal bleeding and pain, which was attributed to radiation proctitis following therapy for adenocarcinoma of the prostate. He subsequently developed a potentially life-threatening complication of sepsis while awaiting follow up care for a spontaneous rectal perforation. The commentary addresses the importance of early identification and timely intervention in the event of treatment failure and the post-discharge follow-up programs to improve care coordination and communication during transitions of care.

Patient and health care professional perspectives on stigma in integrated behavioral health: barriers and recommendations.

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Phelan SM, Salinas M, Pankey T, et al. Ann Fam Med. 2023;21:s56-s60.

Stigma can prevent patients from seeking necessary mental health care. In this study, researchers conducted qualitative interviews with patients and health care providers to assess mental health stigma and barriers to use of integrated behavioral health (IBH) in primary care settings. Participants identified the importance of normalizing discussions about mental health care and patient-centered communication.

Medication errors in community pharmacies: evaluation of a standardized safety program.

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Ledlie S, Gomes T, Dolovich L, et al. Explor Res Clin Soc Pharm. 2023;9:100218.

Mandatory error reporting systems can help identify types, causes, and solutions to medication-related errors. More than 30,000 medication-related incidents were reported by community pharmacists to the Assurance and Improvement in Medication (AIMS) Program in Canada. Event type, severity, medication class, and method of detection are described. Only 60% of pharmacies submitted at least one report, indicating compliance with and participation in the AIMS Program remains low.

AMA Prior Authorization (PA) Physician Survey.

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Chicago, IL: American Medical Association; March 2023.

Insurance policies can have consequences that reduce the safety of medical care. This latest version of the study surveyed 1000 physicians in 2022 to find that prior authorization requirements contributed to patient harm or potentially preventable hospitalization 33 percent of the time.

Do no unconscious harm.

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Ortega RP. Science. 2023;379:870-873.

Implicit biases can degrade decision making as they impact heuristics, test result interpretation, and patient/physician communication. This article highlights efforts to understand implicit biases in health care professionals. It discusses initiatives and tools in development to reduce the presence of unconscious bias in health care.

Using A.I. to detect breast cancer that doctors miss.

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Satariano A, Metz C. New York Times. March 5, 2023.

Artificial intelligence (AI) is an innovation that represents great promise for diagnostic accuracy and timeliness improvement. This article discusses a successful AI breast cancer screening program in Hungary and its potential to illuminate efforts to spread AI-enhanced diagnosis as a tool for physician decision making.

Minimize medication errors in urgent care clinics.

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Coffey SB. American Nurse Journal. Epub March 2, 2023.

Urgent care clinics offer services to a wide patient base that increase the complexities of medication prescribing and administration. Safety culture, process, and structural factors are discussed as avenues to increase safety in this unique ambulatory setting. The piece highlights the importance of education, rules, and storage procedures to ensure safe medication administration.

Ten years of online incident reporting and learning using CPiRLS: implications for improved patient safety.

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Thomas M, Swait G, Finch R. Chiropr Man Therap. 2023;31:9.

Patient safety incident reporting is an important tool for characterizing events and identifying opportunities for patient safety improvements. This longitudinal study describes chiropractic safety incidents reported to an online reporting and learning system used in the UK, Canada, and Australia. One-quarter of incidents related to post-treatment distress or pain. Documented areas for learning and safety improvement included reducing patient falls, improving continuity of care, and improving recognition of serious pathology requiring escalation to other care providers.

Now is the time to routinely ask patients about safety.

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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.

Curated Libraries

Value and Patient Safety

March 8, 2023

Value as an element of patient safety is emerging as an approach to prioritize and evaluate improvement actions. This library highlights resources that explore the business case for cost effective, efficient and impactful efforts to reduce medical errors.

Pharmacists reducing medication risk in medical outpatient clinics: a retrospective study of 18 clinics.

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Snoswell CL, De Guzman KR, Barras M. Intern Med J. 2023;53:95-103.

Community pharmacists play an important role in ensuring patient safety. This retrospective analysis of 18 outpatient pharmacy clinics evaluated pharmacist recommendations and impacts on medication-related safety. Researchers indicated that outpatient pharmacists were effective in resolving 82% of medication-related problems; 18% of these involved high-risk recommendations, such as medication interactions.

The effect of transitions intervention to ensure patient safety and satisfaction when transferred from hospital to home health care-a systematic review.

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Oksholm T, Gissum KR, Hunskår I, et al. J Adv Nurs. 2023;Epub Feb 10.

Transitions of care can increase risks for patient safety events. This systematic review examined the effectiveness of interventions aimed to increase patient safety during transitions of care between the hospital and home. The authors identified several interventions from previously published studies which increased patient safety and/or patient satisfaction and identified factors that contribute to effective transitions of care (i.e., nurse follow-up, pre-discharge patient education, and contact with local healthcare services).

Examples of Medical Device Misconnections.

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Food and Drug Administration. February 23. 2023.

Mismatches of medical device connectors are known factors in therapeutic agent administration failures, despite efforts to redesign equipment and minimize their occurrence. This series of case studies drawn from reports submitted to the Food and Drug Administration illustrates a variety of misconnection scenarios to demonstrate situations that have a range of potential for patient harm.

Towards conceptualizing patients as partners in health systems: a systematic review and descriptive synthesis.

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Vanstone M, Canfield C, Evans C, et al. Health Res Policy Syst. 2023;21:12.

Patient engagement is a cornerstone of patient safety initiatives. This systematic review explored how patients and caregivers are engaged as partners in healthcare, particularly in cancer care and mental health care.

Identifying safety practices perceived as low value: an exploratory survey of healthcare staff in the United Kingdom and Australia.

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Halligan D, Janes G, Conner M, et al. J Patient Saf. 2023;19:143-150.

Reducing low-value tests and treatments has been a focus of patient safety efforts, but less attention has been focused on low-value patient safety practices (PSP). This study describes the concept of “safety clutter” and understanding which PSP are of low-value, ineffective, and could be discontinued. Frequently cited PSP included paperwork, duplication, and intentional rounding.

NHS staff cried in safety interviews, says watchdog.

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Reed J. BBC. February 27, 2023.

Stressful and caustic work environments are known to compromise health care safety and teamwork. This news story discusses an ongoing investigation in the British National Health Service to examine factors in ambulance services that minimize its safety and effectiveness. Clinicians interviewed revealed serious problems with the work cultures.

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