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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 109 Results
Patient Safety Innovation July 31, 2023

Concern over patient safety issues associated with inadequate tracking of test results has grown over the last decade, as it can lead to delays in the recognition of abnormal test results and the absence of a tracking system to ensure short-term patient follow-up.1,2 Missed abnormal tests and the lack of necessary clinical follow-up can lead to a late diagnosis.

Gefter WB, Hatabu H. Chest. 2023;163:634-649.
Cognitive bias, fatigue, and shift work can increase diagnostic errors in radiology. This commentary recommends strategies to reduce these errors in diagnostic chest radiography, including checklists and improved technology (e.g., software, artificial intelligence). In addition, the authors offer practical step-by-step recommendations and a sample checklist to assist radiologists in avoiding diagnostic errors.

ISMP Patient Safety Alert! Acute care edition. May 18, 2023;28(10);1-3.

Dose error-reduction systems (DERS) and drug libraries are tools for use with smart infusion pumps to ensure safe intravenous medication administration. This article discusses infusion problems unrelated to user error that went undetected by the technology and reached patients. Recommendations to minimize similar occurrences include removing the involved device from service and investigating the incident.
Perspective on Safety April 26, 2023

This piece discusses surveillance monitoring of patients in low-acuity units of the hospital to prevent failure to rescue events, its difference from high-acuity continuous monitoring, and its potential applications in other settings.

This piece discusses surveillance monitoring of patients in low-acuity units of the hospital to prevent failure to rescue events, its difference from high-acuity continuous monitoring, and its potential applications in other settings.

Drs. Susan McGrath and George Blike discuss surveillance monitoring and its challenges and opportunities.

Perspective on Safety March 29, 2023

In the past several decades, technological advances have opened new possibilities for improving patient safety. Using technology to digitize healthcare processes has the potential to increase standardization and efficiency of clinical workflows and to reduce errors and cost across all healthcare settings.1 However, if technological approaches are designed or implemented poorly, the burden on clinicians can increase. For example, overburdened clinicians can experience alert fatigue and fail to respond to notifications. This can lead to more medical errors.

In the past several decades, technological advances have opened new possibilities for improving patient safety. Using technology to digitize healthcare processes has the potential to increase standardization and efficiency of clinical workflows and to reduce errors and cost across all healthcare settings.1 However, if technological approaches are designed or implemented poorly, the burden on clinicians can increase. For example, overburdened clinicians can experience alert fatigue and fail to respond to notifications. This can lead to more medical errors.

Lippi G, Simundic A-M, Plebani M. Clin Chem Lab Med. 2020;58:1070-1076.
This paper discusses potential vulnerabilities in the laboratory diagnosis of COVID-19, such as sample misidentification, inappropriate or inadequate sample collection, sample contamination, as well as the challenges to the diagnostic accuracy of current COVID-19 tests.
ISMP Medication Safety Alert! Acute Care Edition. October 24, 2019.
Automated dispensing cabinets (ADCs) have been implemented in hospitals to improve drug administration safety, but with misuse, can cause patient harm. This newsletter article focuses on three primary ADC user-related problems and offers recommendations for reducing factors that minimize their safe use.
WebM&M Case October 30, 2019
Following resection of colorectal cancer, a hospitalized elderly man experienced a pulmonary embolism, which was treated with rivaroxaban. Upon discharge home, he received two separate prescriptions for rivaroxaban (per protocol): one for 15 mg twice daily for 10 days, and then 20 mg daily after that. Ten days later, the patient's wife returned to the pharmacy requesting a refill. On re-reviewing the medications with her, the pharmacist discovered the patient had been taking both prescriptions (a total daily dose of 50 mg daily).
Schmidt T, Kocher DR, Mahendran P, et al. Stud Health Technol Inform. 2019;267:224-229.
Structured communication methods such as SBAR (situation, background, assessment, recommendation) or ISBAR (identify, situation, background, assessment, recommendation)  were developed to improve handoffs in the hospital, particularly from nursing to physicians, and to reduce the impact of poor communication on adverse events. This study presents a digital pocket card incorporating ISBAR standards that can be used by nurses to facilitate patient handoffs and reporting.
Abimanyi-Ochom J, Mudiyanselage SB, Catchpool M, et al. BMC Med Inform Decis Mak. 2019;19:174.
There are challenges to identifying and measuring diagnostic errors in healthcare settings. This systematic review found evidence that team meetings, error documentation, and trigger algorithms in various clinical settings may reduce diagnostic errors. The authors also found that while there have been numerous studies on interventions targeting diagnostic errors, few such interventions are being used in clinical settings.
Najafzadeh A, Woodrow N, Thoirs K. Australas J Ultrasound Med. 2019;22:206-213.
Distractions are known to be a significant patient safety issue in many settings. This study examined the impact of distractions during obstetric ultrasounds and sonographers expressed concern that distractions increased false negative screenings and could lead to missed diagnoses.  
Mays JA, Mathias PC. J Am Med Inform Assoc. 2019;26:269-272.
Point-of-care test results are often manually transcribed into the electronic health record, which introduces risks of manual transcription errors. The authors of this study took advantage of a redundant workflow in which point-of-care blood glucose results were uploaded and also manually entered by staff. They estimate that 5 in 1000 manually entered results contain clinically significant transcription errors and call for interfacing point-to-care instruments as a patient safety strategy.
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.
Massalha S, Clarkin O, Thornhill R, et al. Can J Cardiol. 2018;34:827-838.
Decision support tools can help reduce diagnostic uncertainty. Discussing how artificial intelligence can be utilized to inform diagnostic decision making and improve the accuracy of cardiac image interpretation, this review suggests that use of such technology can reduce production pressure and cognitive load for imaging physicians.
Taylor-Phillips S, Jenkinson D, Stinton C, et al. Radiology. 2018;287:749-757.
This retrospective analysis of more than 800,000 mammograms examined the effect of a second review of images. With a second reader, fewer women had to return for more imaging and more cancers were detected, suggesting that double reading may enhance the diagnostic performance of mammography.
Ford E, Evans SB. Med Phys. 2018;45:e100-e119.
Learning from adverse events is a core component of patient safety improvement. This review explores the application of this concept in radiation oncology, successful practices, and challenges for incident learning system implementation in the specialty.

Bruno MA, Johnson K, Argy N, Graber ML, eds. Diagnosis. 2017;4(3):111-191.

Radiology plays a unique role in the determination of a diagnosis. Cognitive and system elements in radiology can contribute to overuse, diagnostic error, and delays. Articles in this special issue discuss communication, information overload, and uncertainty in radiology and describe projects working toward improving safety of radiological imaging.
Waite S, Scott JM, Gale B, et al. AJR Am J Roentgenol. 2017;208:739-749.
Interpretive radiology errors can result in delays that contribute to patient harm. This commentary describes human factors that affect diagnostic accuracy and reviews strategies to address weaknesses at the individual and systems level.