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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 212 Results
Patient Safety Primer August 30, 2023
Anyone can find it challenging to understand medical terms, and millions of Americans have trouble understanding and acting upon health information. The mismatch between individuals' health literacy skills and the complexity of health information and health care tasks involved in managing health has implications on patient safety.
Carroll AR, Schlundt D, Bonnet K, et al. Hosp Pediatr. 2023;13:325-342.
Accurate dosing and administration of liquid medications to children can be difficult for parents or caregivers. In this study, family caregivers and clinicians described their experiences at hospital discharge relating to both general and liquid-specific medication counseling. Clinicians and caregivers both stated that teach-back protocols were helpful but inconsistently used. Caregivers were not always shown how to draw up liquid into the syringes leading to them feeling uncertain about giving the correct dose. Health literacy and speaking languages other than English were also described as challenges.
Coleman C, Birk S, DeVoe J. JAMA Intern Med. 2023;183:753-754.
Low personal health literacy is associated with increased post-discharge adverse events and health inequities. This commentary describes organizational strategies to improve health literacy, including elimination of jargon in written and spoken communications and assessment of health professionals’ patient-centered communication tools.
Ekstedt M, Nordheim ES, Hellström A, et al. BMC Health Serv Res. 2023;23:581.
Remote patient monitoring (RPM) allows patients to remain in their homes while still receiving disease management. This study involved patients with chronic conditions who were receiving RPM and clinicians (nurses and physicians) who were providing RPM. Clinicians described the importance of knowing patients' level of health literacy and ensuring they understand when someone is reviewing their remote data (e.g., not on weekends). Patients reported feeling more confident, knowing someone was checking on them weekly. Overall, both groups had positive perceptions of patient safety.

May 31, 2023; Fed Register;88:35694-35728.

Standardized medication labels have been shown to increase patient comprehension and adherence. The Food and Drug Administration (FDA) is proposing a rule which, if approved, would require an easily understandable, one-page medication guide be given to patients when receiving medication in the outpatient setting. Written comments may be submitted through November 27, 2023.
Denecke K. Stud Health Technol Inform. 2023;302:157-161.
The public is increasingly using conversational assistants like Siri, Alexa, and Google Assistant to find medical advice and self-diagnose. This narrative review summarizes three facets of safety: system (data privacy/security), patient (risks of acting on inaccurate information), and perceived (patient trust in the system). Future research should address all three safety facets, and the results should be transparent to consumers.
Patient Safety Primer May 31, 2023

Anyone can find it challenging to understand medical terms, and millions of Americans have trouble understanding and acting upon health information. Health literate organizations make health systems easier to navigate and health information easier to understand, improving healthcare delivery and outcomes.

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.
Oakbrook Terrace, IL: Joint Commission. 2002-2023.
A series of patient safety brochures, videos and infographics directed toward specific areas of care that encourages patients to take an active role by asking questions and addressing problems with their providers. Topics include preventing falls, medication safety, and safe surgery. Available in both English and Spanish.

Shaikh U, van der List L, Blumberg D. Kids Considered. March 27, 2023.

Medication administration at home can be problematic especially for parents caring for children. This podcast highlights common reasons for medication mistakes at home and how they can be avoided. Simple steps such as not using regular spoons as methods of delivering liquid medications are highlighted.
Lindberg C, Fock J, Nilsen P, et al. Scand J Caring Sci. 2022.
Providing in-home care for home-dwelling adults presents unique patient safety challenges. This qualitative study with 13 registered nurses in Sweden explored how nurses ensure safe home health care among home-dwelling older patients. Findings highlight the importance of continuity of care, trust between patients, caregivers, and nurses, and adapting safety requirements to meet environmental conditions and maintain a sense of home.
Van der Voorden M, Ahaus K, Franx A. BMJ Open. 2023;13:e063175.
Patient engagement in healthcare is widely encouraged, but findings from some studies suggest that patient participation can have negative effects. This qualitative study with 16 patients and obstetric healthcare professionals examined the negative effects of patient participation in healthcare. Researchers identified four types of negative consequences from patient participation in safety – decreases in patient confidence, eroding of the patient-professional relationship, unwanted increases in patient responsibility, and excess time spent by professionals on the patient.
Gotlieb R, Praska C, Hendrickson MA, et al. JAMA Netw Open. 2022;5:e2242972.
Ensuring patients understand their diagnosis and care plan is important to achieving optimal outcomes. However, patients routinely report not understanding what their provider has told them. In this study, adults were asked for their understanding of jargon clinicians regularly use (“negative” test results, NPO) and a corresponding statement without jargon (“you do not have an infection”, “nothing by mouth”). Some jargon was better understood (“negative”) than other jargon (“occult infection”). Participant demographics were not significantly associated with understanding jargon.

Eldeib D. ProPublica. November 13, 2022.

Pregnancy is recognized as a high-risk condition for both mother and infant. This news story examines the potential for stillbirth and its preventability. Lack of respect for the concerns of mothers, inadequate attention to research, and poor patient education are discussed as contributors to stillbirth.
Newman B, Joseph K, McDonald FEJ, et al. Health Expect. 2022;25:3215-3224.
Patient engagement focuses on involving patients in detecting adverse events, empowering patients to speak up, and emphasizing the patient’s role in a culture of safety. Young people ages 16-25 with experiences in cancer care, and staff who support young people with cancer were asked about their experiences with three types of patient engagement strategies. Four themes for engaging young people emerged, including empowerment, transparency, participatory culture, and flexibility. Across all these was a fifth theme of transition from youth to adult care.  
Boisvert S. J Healthc Risk Manag. 2022;42:18-25.
Social determinants of health (SDOH) are non-medical factors that impact a person’s health and well-being. This commentary presents ways that risk managers can improve equity and patient safety by addressing two SDOH: health literacy and discrimination. The author recommends using existing risk management tools (e.g., error reporting, data collection) to develop strategies to address the negative impacts of SDOH.
WebM&M Case September 28, 2022

This case describes a 20-year-old woman was diagnosed with a pulmonary embolism and occlusive thrombus in the right brachial vein surrounding a  peripherally inserted central catheter (PICC) line (type, gauge, and length of time the PICC had been in place were not noted). The patient was discharged home but was not given any supplies for cleaning the PICC line, education regarding the signs of PICC line infection, or referral to home health services.

Lear R, Freise L, Kybert M, et al. J Med Internet Res. 2022;24:e37226.
As patients increasingly access their electronic health records, they often identify errors requiring correction. This survey of 445 patients in the United Kingdom found that the majority of patients are willing and able to identify and respond to errors in their electronic health records, but information-related and systems-related barriers (e.g., limited understanding of medical terminology, poor information display) disproportionately impact patients with lower digital health literacy or language barriers.
Mercer AN, Mauskar S, Baird JD, et al. Pediatrics. 2022;150:e2021055098.
Children with serious medical conditions are vulnerable to medical errors. This prospective study examined safety reporting behaviors among parents of children with medical complexity and hospital staff caring for these patients in one tertiary children’s hospital. Findings indicate that parents frequently identify medical errors or quality issues, despite not being routinely advised on how to report safety concerns.
Khan A, Parente V, Baird JD, et al. JAMA Pediatr. 2022;176:776-786.
Parent or caregiver limited English proficiency (LPE) has been associated with increased risk of their children experiencing adverse events. In this study, limited English proficiency was associated with lower odds of speaking up or asking questions when something does not appear right with their child’s care. Recommendations for improving communication with limited English proficiency patients and families are presented.