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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 1245 Results
WebM&M Case March 29, 2023

This case describes a 13-year-old girl who presented to several health care providers with typical symptoms, physical signs, and early laboratory findings suggestive of adrenal insufficiency (AI) yet the diagnosis was delayed for several months due to diagnostic biases. After she suffered a sudden cardiac arrest during a visit to her local emergency department and was airlifted to a tertiary care facility, she was found to be in adrenal crisis secondary to Addison’s disease.

Xiao K, Yeung JC, Bolger JC. Eur J Surg Oncol. 2023;49:9-15.
The COVID-19 pandemic has increased adoption of telehealth across various medical specialties, including surgery and oncology. This systematic review including 11 studies (3,336 patients) explored the impact of virtual follow-up appointments after cancer operations. The authors concluded that virtual visits following cancer surgery had similar safety to in-person visits along with high levels of satisfaction for surgeons and patients.
Agbar F, Zhang S, Wu Y, et al. Nurse Educ Pract. 2023;67:103565.
Health systems seeking to improve patient safety culture (PSC) implement myriad of educational programs for their staff. This review identified 16 studies of PSC education programs that included before and after surveys or intervention and control groups. Results were generally positive, but repeated trainings may be needed to sustain the change. Additionally, based on the reporting using the AHRQ Hospital Survey of Patient Safety Culture (HSOPS), a culture of blame remained a pervasive problem despite improvements in other components of patient safety culture in many hospitals.
Bates DW, Williams EA. J Allergy Clin Immunol Pract. 2022;10:3141-3144.
Electronic health records (EHRs) are key for the collection of patient care data to inform overarching risk management and improvement strategies. This article discusses the adoption of EHRs as tools supporting patient safety and highlights the need for an expanded technology infrastructure to continue making progress.

Oregon Patient Safety Commission: 2023.

Gaslighting has been identified as a contributor to maternal mortality and morbidity. This toolkit of compiled resources aims to help inform organizational activities to establish programs and strategies to reduce the impact of disrespect, implicit bias and inequities that affect the care of pregnant persons.
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.
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.
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.
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.

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.

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.

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. 
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.

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.
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.
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.
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
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.
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.