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.

Search All Content

Clear all filter(s)

Displaying 1 - 20 of 215 Results

Diagnostic error among vulnerable populations presenting to the emergency department with cardiovascular and cerebrovascular or neurological symptoms: a systematic review.

Save to Library

Herasevich S, Soleimani J, Huang C, et al. BMJ Qual Saf. 2023;Epub Mar 27.

Vulnerable populations, such as those with limited English proficiency, minoritized race or ethnicity, migrant populations, or patients qualifying for public insurance, may be at higher risk for adverse health events. In this review, researchers sought to identify frequency and causes of diagnostic error of vulnerable populations presenting to the emergency department with cardiovascular or cerebrovascular/neurological symptoms. Black patients presenting with cardiovascular symptoms had significantly higher odds of diagnostic error. Other demographic factors did not show similar associations, nor did studies of patients with cerebrovascular/neurological symptoms.

Surgeons and systems working together to drive safety and quality.

Save to Library

Hawkins RB, Nallamothu BK. BMJ Qual Saf. 2023;32:181-184.

A 2022 study found that non-first off-pump coronary artery bypass graft (CABG) had a higher risk of complications than first cases, proposing prior workload as a contributing cause. This commentary responds to that study, proposing system and organizational factors, not just the individual surgeon, be taken into consideration as contributing causes.

Enhancing Support for Patients’ Social Needs to Reduce Hospital Readmissions and Improve Health Outcomes

Save to Library

Patient Safety Innovation March 29, 2023

With increasing recognition that health is linked to the conditions in which a patient lives, health systems are looking for innovative ways to support recently discharged patients in their lives outside of the hospital. In a recent innovation, Prime Healthcare Services, Inc., which includes a network of 45 hospitals, provided social needs assessments and strengthened its partnerships with community agencies to support the health of high-needs patients after their discharge from the hospital.

Association between unmet nonmedication needs after hospital discharge and readmission or death among acute respiratory failure survivors: a multicenter prospective cohort study.

Save to Library

Bose S, Groat D, Dinglas VD, et al. Crit Care Med. 2023;51:212-221.

Medication discrepancies at discharge are a known contributor to hospital readmission, but nonmedication needs may also contribute. In this study, 200 survivors of acute respiratory failure were followed up 7-28 days post discharge to assess unmet nonmedication discharge needs (i.e., durable medical equipment, home health services, follow-up medical appointments). Nearly all patients had at least one unmet need, but this was not associated with hospital readmission or mortality within 90 days.

Curated Libraries

Diagnostic Errors Case Studies

January 19, 2023

The Primary-Care Research in Diagnosis Errors (PRIDE) Learning Network was a Boston-based national effort to improve diagnostic safety. Hosted by the State of Massachusetts’ Betsy Lehman Center, it was led by the Harvard Brigham and Women’s Center for Patient Safety Research and Practice with funding from the Gordon and Betty Moore Foundation. ...

Mechanical Prosthetic Valve Thrombosis with Thromboembolism.

Save to Library

WebM&M Case November 16, 2022

A 61-year-old women with a mechanical aortic valve on chronic warfarin therapy was referred to the emergency department (ED) for urgent computed tomography (CT) imaging of the right leg to rule out an arterial clot. CT imaging revealed two arterial thromboses the right lower extremity and an echocardiogram revealed a thrombus near the prosthetic heart valve. The attending physician ordered discontinuation of warfarin and initiation of a heparin drip.

A System in Need of Repair: Addressing Organizational Failures of the U.S.’s Organ Procurement and Transplantation Network.

Save to Library

US Senate Finance Committee. 117th Cong (2021-2022). August 3, 2022.

Organ transplantation processes require reliable communication and technical expertise to ensure safety for organ delivery and patient care. This hearing discussed the findings of a United States Senate investigation into waste and harm in the US organ transplant system. Blood-type mistakes, transport failures, and process challenges were amongst the problems discussed.

Safety gaps in medical team communication: closing the loop on quality improvement efforts in the cardiac catheterization lab.

Save to Library

Doorey AJ, Turi ZG, Lazzara EH, et al. Catheter Cardiovasc Interv. 2022;99:1953-1962.

Closed loop communication (CLC) ensures a clear transfer of information by having the recipient repeat the order for verification. In this study, procedures in the cardiac catheterization lab were observed to assess the frequency and accuracy of CLC. Despite three interventions over five years (education, on-going feedback, accountability), CLC remained suboptimal, with both incomplete orders given and incomplete responses.

Management of Cardiac Arrest in Unconventional Locations.

Save to Library

WebM&M Case May 16, 2022

This WebM&M describes two cases involving patients who became unresponsive in unconventional locations – inside of a computed tomography (CT) scanner and at an outpatient transplant clinic – and strategies to ensure that all healthcare teams are prepared to deliver advanced cardiac life support (ACLS), such as the use of mock codes and standardized ACLS algorithms.

Central venous catheter guidewire retention: lessons from England's never event database.

Save to Library

Mariyaselvam MZA, Patel V, Young HE, et al. J Patient Saf. 2022;18:e387-e392.

A retained foreign object can lead to serious clinical consequences and is considered a never event. Researchers analyzed a national patient safety incident database to identify factors contributing to guidewire retention and potential preventative measures. Findings indicate that most retained guidewires are identified after the procedure. The authors suggest that system changes or design modifications to central venous catheter equipment is one approach to prevent guidewire attention.

Learning environments, reliability enhancing work practices, employee engagement, and safety climate in VA cardiac catheterization laboratories.

Save to Library

Gilmartin HM, Hess E, Mueller C, et al. Health Serv Res. 2022;57:385-391.

Ideal clinical learning environments (CLE) support employee engagement, satisfaction, and a culture of safety. The Learning Environment and High Reliability Practices Survey (LEHR) was used to determine the association between ideal CLE and job satisfaction, burnout, intent to leave, and staff turnover. Learning environments with higher average LEHR scores were associated with higher employee engagement, retention, and safety climate scores.

Hospital-acquired functional decline and clinical outcomes in older cardiac surgical patients: a multicenter prospective cohort study.

Save to Library

Morisawa T, Saitoh M, Otsuka S, et al. J Clin Med. 2022;11:640.

Hospital-acquired functional decline can lead to poor health outcomes for frail older adults. This multicenter, prospective cohort study set in Japan assessed the effect of hospital-acquired function decline on post-discharge outcomes among older adults who had undergone cardiac surgery. The study observed poor prognostic outcomes in one-third of patients. Hospital-acquired functional decline was an independent predictor of poor prognosis. The authors encourage hospitals to develop and implement approaches to preventing functional decline in older adults.

Diagnostic reasoning in cardiovascular medicine.

Save to Library

Brush JE, Sherbino J, Norman GR. BMJ. 2022;376:e064389.

Misdiagnosis of heart failure can lead to serious patient harm. This article reviews the cognitive psychology of diagnostic reasoning in cardiology. Strategies for educators, students, and researchers to reduce cardiovascular misdiagnosis are presented.

Association of differences in treatment intensification, missed visits, and scheduled follow-up interval with racial or ethnic disparities in blood pressure control.

Save to Library

Fontil V, Pacca L, Bellows BK, et al. JAMA Cardiol. 2022;7:204-212.

Racial and ethnic inequities are increasingly being linked to health disparities. This study of more than 16,000 patients explored the association between race and ethnicity and blood pressure control. Findings suggest racial and ethnic inequities in treatment intensification may be associated with more than 20% of observed racial or ethnic disparities in blood pressure control.

Hospital Performance Report.

Save to Library

Trenton, NJ: New Jersey Department of Health and Senior Services.

Detailing results of an error reporting initiative in New Jersey, these reports explain how consumers can use this information and provides tips for safety when obtaining health care. A section highlights findings related to patient safety indicators.

Misdiagnosis of acute myocardial infarction: a systematic review of the literature.

Save to Library

Kwok CS, Bennett S, Azam Z, et al. Crit Pathw Cardiol. 2021;20:155-162.

Misdiagnosis of cardiovascular conditions can lead to serious patient harm. This systematic review found that misdiagnosis of acute myocardial infarction (AMI) occurs in approximately 1-2% of cases, and AMI is commonly diagnosed as other heart conditions, musculoskeletal pain, or gastrointestinal disease. The authors suggest that there are opportunities to reduce cases of missed AMI with better education about atypical symptoms and improved training of electrocardiogram interpretation.

Achieving Excellence in the Diagnosis of Acute Cardiovascular Events: Proceedings of a Workshop–in Brief.

Save to Library

National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2021.

Misdiagnosis of severe cardiovascular events is a primary concern to the diagnostic safety community due to its prevalence and potential for harm. This report summarizes a session discussion on the existing evidence base on improving diagnosis for these conditions and explore opportunities for improvement.

‘He thought what he was doing was good for people.’ Why is it so difficult to prevent unnecessary medical procedures in the U.S. health-care system?

Save to Library

Outcalt C. The Atlantic. August 2021.

Overuse and unnecessary care lead to serious patient harms and a cascade of negative consequences. This story describes the overuse behavior of one surgeon to illustrate influences contributing to the problem.

Patient harm from cardiovascular medications.

Save to Library

Paradissis C, Cottrell N, Coombes ID, et al. Ther Adv Drug Saf. 2021;12:204209862110274.

Adverse drug events are a common source of harm in both inpatient and ambulatory patients. This narrative review of 75 studies concluded that cardiovascular medications are a leading cause of medication harm across different clinical settings, and that older adults are at increased risk. Medications to treat high blood pressure and arrhythmias were the most common cause of medication harm.

Pharmacist-led intervention on the reduction of inappropriate medication use in patients with heart failure: a systematic review of randomized trials and non-randomized intervention studies.

Save to Library

Hernández-Prats C, López-Pintor E, Lumbreras B. Res Social Adm Pharm. 2022;18:2748-2756.

Clinical pharmacists play an important role in ensuring patient safety, particularly in interventions aimed at reducing polypharmacy. This review focused on interventions involving pharmacists to reduce polypharmacy and inappropriate medications for patients with heart failure. Findings indicate interventions are most successful when specific guidelines or recommendations to assess appropriate prescribing of heart failure medications are followed.

The PSNet Collection: All Content

Search All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

The PSNet Collection: All Content

Search All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Case

Continue as a Guest

Continue Logged In

Submit Your Case

Continue as a Guest

Already have a PSNet

Account?

New Users

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site