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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 3046 Results
Staal J, Zegers R, Caljouw-Vos J, et al. Diagnosis (Berl). 2022;10:121-129.
Checklists are increasingly used to support clinical and diagnostic reasoning processes. This study examined the impact of a checklist on electrocardiogram interpretation in 42 first-year general practice residents. Findings indicate that the checklist reduced the time to diagnosis but did not affect accuracy or confidence.
Dietl JE, Derksen C, Keller FM, et al. Int J Environ Res Public Health. 2023;20:5698.
Miscommunication between healthcare providers can contribute to adverse events, but communication may be improved by strengthening psychological safety. This paper describes two studies on the association of communication, patient safety threats, and higher quality care and the mediating effect of psychological safety in obstetrical care. Results suggest psychological safety mediates the association of communication with quality of care and patient safety.

Farnborough, UK: Healthcare Safety Investigation Branch; April 2023.

Gaps in patient information processes can result in missed care opportunities that contribute to harm. This report examines language discordance in National Health Service written scheduling communications and its contribution to patients being lost to follow up. The primary improvement recommendation is to enhance the ability of providers to recognize primary languages of patients and provide written instructions accordingly.
Poiraud C, Réthoré L, Bourdon O, et al. Infect Dis Now. 2023;53:104641.
Vaccine errors can limit the effectiveness of immunization efforts. Based on survey data from 227 health professionals in France, this study identified several areas for improvement related to knowledge of vaccine-related errors, such as contraindications during pregnancy, vaccine storage, age-related vaccine schedules, and vaccine administration.
Hyvämäki P, Sneck S, Meriläinen M, et al. Int J Med Inform. 2023;174:105045.
Insufficient or incorrect transfer of patient information, whether caused by human or organizational factors, can result in adverse events during transitions of care. This study used four years of incident reports to identify the types, causes, and consequences of health information exchange- (HIE) related patient safety incidents in emergency care, (ED) emergency medical services (EMS), or home care. The two main kinds of HIE-related incidents were (1) inadequate documentation and inadequate use of information (e.g., deficiencies in content), and (2) causes related to the health professional or organization; consequences were adverse events or additional actions to prevent, avoid, and correct adverse events.
Jeffries M, Salema N-E, Laing L, et al. BMJ Open. 2023;13:e068798.
Clinical decision support (CDS) systems were developed to support safe medication ordering, alerting prescribers to potential unsafe interactions such as drug-drug, drug-allergy, and dosing errors. This study uses a sociotechnical framework to understand the relationship between primary care prescribers’ safety work and CDS. Prescribers described the usefulness of CDS but also noted alert fatigue.

Patel J. PM Healthcare Journal. Spring 2023(4):5-18.

Language discordance is known to degrade medication safety. The article discusses an examination of English pharmacists’ reactions and responses to language barriers with patients. The results highlight the need for improved training and support for pharmacists to effectively dispense medications and counsel patients with whom they don’t share a common language.

Epsom and St Helier University Hospitals. Epsom, UK: National Health Service; March 21, 2023.

The Systems Engineering Initiative for Patient Safety (SEIPS) framework is an established human factors-based approach to designing care system improvements. This video introduces the concepts behind SEIPS and uses an everyday non-clinical activity to illustrate its use for a broad audience to identify problems.
Machen S. BMJ Open Qual. 2023;12:e002020.
Learning from patient safety incidents can help health care organizations improve processes and care delivery. This article provides a template for organizations to review patient safety incidents and classify them into themes from a human factors and systems thinking perspective. The process involves clearly characterizing the safety incidents, describing the involved safety systems, identifying and classifying contributing factors, completion of narrative analysis to identify commonalities and differences in the way contributing factors affect the incidents, and identification of safety recommendations. 

Farnborough, UK: Healthcare Safety Investigation Branch; April 2023.

Misattribution of child maltreatment injuries can be a serious misdiagnosis affecting families and patients. This report analyzes ten safety incident reports from across the British National Health Service to explore how non-accidental injury was missed. Themes identified as contributing to the problems include lack of information sharing, inconsistent guidance, and emergency department care demands.

Powell M. J Health Org Manag. 2023;37(1):67-83.

Individual, team, and organizational willingness to identify and address safety problems is an important indicator of safety culture. The authors of this article apply ten perspectives on organizational silence to understand the organizational failures contributing to dangerous opioid prescribing practices at Gosport Hospital.
Garzón González G, Alonso Safont T, Zamarrón Fraile E, et al. Int J Qual Health Care. 2023;35:mzad019.
Research into the nature, type, and contributing factors of adverse events (AE) in primary care is required to develop successful safety interventions. This study used medical record review to determine the prevalence, preventability, severity, type, and contributory factors of AE in primary care in Madrid, Spain. The prevalence of AEs was 5%, with the majority determined to be preventable. Most resulted in mild harm, and most contributory factors were patient-related (e.g., self-administered medications).
Donzé JD, John G, Genné D, et al. JAMA Internal Med. 2023;Epub May 1.
Adverse events and unplanned, preventable readmissions occur in approximately 20% of patients following discharge from the hospital. This randomized clinical trial compares standard care with a multi-modal discharge intervention targeting patients at highest risk of unplanned readmission. Despite the intensity of the intervention, there was no statistical difference between that intensity and the standard of care in unplanned readmission, time to readmission, or death.
Correia T, Martins MM, Barroso F, et al. Nurs Rep. 2023;13:634-643.
Family involvement in care can have mixed results for patient safety. Interviews with nurses show seven ways families can hinder safety and ten ways they improve safety. The risk of infection was the greatest safety threat and being a unique source of information helped increase patient safety. Interestingly, "greater workload for nurses" was identified as a facilitator of patient safety, potentially, as it lowered the stress experienced by the nurse and increased family satisfaction and positive involvement.
Comolli L, Korda A, Zamaro E, et al. BMJ Open. 2023;13:e064057.
Patients presenting to the emergency department (ED) with a chief complaint of dizziness require prompt assessment to rule in or out a serious diagnosis such as stroke. A retrospective chart review was performed on more than 1,500 adult patients presenting to the ED with dizziness to estimate vestibular syndrome classifications (i.e., acute, episodic, chronic) and rates of misdiagnosis. Approximately 20% of patients were diagnosed with acute vestibular syndrome (e.g., stroke) and 10% had an unclear vestibular syndrome at time of ED discharge. Of those with follow-up exams, nearly one-third received a different diagnosis, but only 3.2% received a different vestibular classification.
Salmon PM, Hulme A, Walker GH, et al. Ergonomics. 2023;66:644-657.
Systems thinking concepts are used by healthcare organizations to encourage learning from failures and identifying solutions to complex patient safety problems. This article outlines a refined and validated set of systems thinking tenets and discusses how they can be used to proactively identify threats to patient safety.
Passini L, Le Bouedec S, Dassieu G, et al. BMJ Qual Saf. 2023;Epub Mar 14.
Medical errors in the neonatal intensive care unit (NICU) are common and can result in significant patient harm. This prospective observational study conducted at 10 NICUs in France found that approximately 41% of the 1,822 errors (among 1,019 patients) were disclosed to the patient’s parents. Providers cited parental absence (i.e., the error occurred overnight) and perceived lack of serious consequences for the infant as the most frequent reason for non-disclosure.
Mortsiefer A, Löscher S, Pashutina Y, et al. JAMA Netw Open. 2023;6:e234723.
Polypharmacy among older adults can cause adverse health outcomes as well as adversely impact social outcomes, medication management, and healthcare utilization. The COFRAIL cluster randomized trial explored whether family conferences can promote deprescribing and reduce adverse outcomes related to polypharmacy in community-dwelling frail older adults. After 12 months of follow-up, the researchers did not find any significant difference in hospitalizations among patients randomized to family conferences or usual care. The number of potentially inappropriate prescriptions decreased among patients randomized to family conferences at 6-month follow-up, but this reduction was not sustained at the 12-month follow-up.
Kirwan G, O’Leary A, Walsh C, et al. Eur J Hosp Pharm. 2023;30:86-91.
Patients are particularly vulnerable to medication errors during transitions of care, such as hospital discharge. Based on clinical judgement from four experts assessing 81 cases involving medication errors at discharge, the authors estimated that between 61-85% would result in additional healthcare utilization (e.g., additional prescriptions, primary care or ED visits, hospital or ICU admissions) and additional costs.
de Arriba Fernández A, Sánchez Medina R, Dorta Hung ME, et al. J Patient Saf. 2023;19:249-250.
As more patients with COVID-19 were admitted to hospitals during the pandemic, concerns about healthcare-acquired COVID-19 and potential associated adverse events increased. In this retrospective study, 126 patients with hospital-acquired COVID-19 were moved to isolation or quarantine. Twenty-nine patients experienced one or more adverse events due to isolation or quarantine, including delayed transfer to other specialties and delayed diagnostic tests. Nosocomial COVID-19 infection was confirmed as cause of death in one patient, and a possible cause in 11 others.