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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 2048 Results
Wallin A, Ringdal M, Ahlberg K, et al. Scand J Caring Sci. 2023;37:414-423.
Numerous factors can hinder safe radiology practices, such as communication failures and image interpretation errors. Based on semi-structured interviews with 17 radiologists in Sweden, this study identified 20 themes at the individual-, organization-, technology-, task-and environment-levels describing factors supporting patient safety in radiology. Factors described by participants included the use of standardized tools and work routines (e.g., checklists), handoffs, and incident reporting systems.

Zucchelli G, Stefanini M, eds. Periodontol 2000. 2023;92(1):1-398.

Patient safety in dentistry shares common challenges with medicine and their emergence in a distinct care environment. This special issue covers a range of adverse events and treatment mistakes associated with periodontal procedures. Topics examined include human factors, implant placement and methodologic bias.

ECRI. ECRI Headquarters, Plymouth Meeting, PA, October 11-12, 2023. 9:00 AM – 4:45 PM (eastern).

Human factors engineering (HFE) is a core approach to improving the reliability and safety of complex practice. This conference will provide direction in understanding how to proactively define risks and design processes to reduce the potential for failure.

Armstrong Institute for Patient Safety and Quality, Baltimore, MD. October 3-4, 2023.

Human factors engineering (HFE) is a primary strategy for advancing safety in health care. This virtual workshop will introduce HFE methods and discuss how they can be used to reduce risk through design improvements in a variety of process and interpersonal situations.
Lee B, Marhalik-Helms J, Penzi L. Jt Comm J Qual Patient Saf. 2023;49:441-449.
Perioperative and anesthesia care present unique patient safety challenges. This article describes the development and implementation of the Anesthesia Risk Alert (ARA) program, which promotes collaborative clinical decision-making and recommends risk mitigation strategies to address specific high-risk clinical scenarios. Since implementation began in 2019, ARA compliance has exceeded 90% and has reduced the rate of adverse events among certain high-risk patients, such as those with a high body mass index.
WebM&M Case August 30, 2023

This case describes a 27-year-old primigravid woman who requested neuraxial anesthesia during induction of labor. The anesthesia care provider, who was sleep deprived near the end of a 48-hour call shift (during which they only slept for 3 hours), performed the procedure successfully but injected an analgesic drug that was not appropriate for this indication. As a result, the patient suffered slower onset of analgesia and significant pruritis, and required more prolonged monitoring, than if she had received the correct medication.

Hooftman J, Dijkstra AC, Suurmeijer I, et al. BMJ Qual Saf. 2023;Epub Aug 9.
Diagnostic errors are common and have many contributing factors. This study analyzed more than 100 serious adverse event (SAE) reports in acute care using four investigation methods (e.g., Diagnostic Error Evaluation Research (DEER) taxonomy, Safer Dx Instrument) to identify common contributing factors. Transitions of care were particularly vulnerable to SAE, often due to incomplete communication between departments. Diagnostic errors occurred most often in the testing, assessment, and follow-up phases, with human factors as the most common contributing factor. Using multiple investigative methods supports more targeted interventions in each phase of diagnosis.
Webster CS, Mahajan R, Weller JM. Br J Anaesth. 2023;131:397-406.
Systems involving people, tools, technology, and work environments must interact effectively to ensure the delivery of safe, effective care. This narrative review uses a sociotechnical perspective to explore the inter-relationship between technology and the human work environment during the delivery of anesthesia in the operating room. The authors discuss systems-level approaches, such as such as surgical safety checklists, as well as the role of resilience and new technologies (i.e., artificial intelligence).
Kinsella SM, Boaden B, El‐Ghazali S, et al. Anaesthesia. 2023;78:1285-1294.
Anesthesia provision is a high-risk practice. This guidance provides practical steps to ensure perioperative medication delivery is as safe as possible. This material recommends approaches for both clinicians and organizations to enable collaborative safety efforts in anesthesia, including prefilled syringes, standardization, and adherence to safe labeling practices.
Bijok B, Jaulin F, Picard J, et al. Anaesth Crit Care Pain Med. 2023;42:101262.
Human factors influence how humans and systems interact to make processes more reliable or more error-prone during both normal and unexpected circumstances. This guideline provides recommendations centered on elements of communication, the organization, the work environment, and training to guide the consideration of human factors in improvement actions during critical anesthesia or intensive care situations.
Estock JL, Codario RA, Keddem S, et al. Diabetes Technol Ther. 2023;25:343-355.
Insulin pump malfunctions are a known contributor to adverse events. This study used six months of adverse events reported to the Food and Drug Administration's (FDA) Manufacturer and User Facility Device Experience (MAUDE) database to identify root causes and consequences of errors associated with insulin pump malfunctions. Hyper- and hypoglycemia were the most common clinical consequences of the malfunction; only half of the reports identified a potential root cause.
Joshi RN, Kalaminsky S, Feemster A-A, et al. Jt Comm J Qual Patient Saf. 2023;Epub Jun 24.
Technology, such as barcode scanning, is a recognized method for improving medication safety, but poor design may lead to alert fatigue. This article describes a quality improvement project to reduce barcode-assisted medication preparation alerts in the hospital's pharmacies. More than 40% of alerts were identified as "barcode not recognized," such as packages containing more than one barcode. Problems associated with the highest volume of alerts were resolved with staff education, workflow changes, and changes.
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.

WebM&M Case July 31, 2023

A 50-year-old unhoused patient presented to the Emergency Department (ED) for evaluation of abdominal pain, reportedly one day after swallowing multiple sharp objects. Based on the radiologic finding of an open safety pin or paper clip in the distal stomach, he was appropriately scheduled for urgent esophagogastroduodenoscopy and ordered to remain NPO (nothing by mouth) to reduce the risk of aspirating gastric contents.

Arredondo Montero J, Bardají Pascual C. Clin Pediatr (Phila). 2023;Epub May 29.
Human factors strategies are increasingly applied in health care to mitigate the impact of human error in medicine. This article discusses the use of checklists to systematize anesthesia and reduce risk in pediatric surgery.
Starmer AJ, Michael MM, Spector ND, et al. Jt Comm J Qual Patient Saf. 2023;49:384-393.
Multiple handoffs during perioperative care present opportunities for error. This article outlines a conceptual framework to support the development, implementation, and evaluation of patient-centered handoffs during perioperative care. The authors describe a multi-component handoff improvement bundle including mnemonics and checklists (such as I-PASS), technology solutions to reinforce verbal handoffs, interprofessional handoff training and assessment, and leadership support to promote safety culture.
Ly DP, Shekelle PG, Song Z. JAMA Intern Med. 2023;183:818-823.
Anchoring bias is the tendency to focus on an initial diagnosis despite later evidence to the contrary. This study measured physicians’ potential anchoring bias regarding patients with congestive heart failure (CHF) with shortness of breath presenting to the emergency department. When the patient’s initial triage note included CHF, physicians were less likely and/or slower to test for pulmonary embolism (PE) than when the triage note did not mention CHF. This suggests physicians may have been subject to anchoring bias.
Godin MR, Nasr AS. J Nurs Adm. 2023;53:331-336.
Hospital design has been associated with patient safety incidents. This study compared rates of medication administration errors in the pediatric unit of a new evidence-based design (EBD) hospital with rates at the older facility prior to moving to the EBD hospital. Despite implementing EBD, rates of distractions were lower at the older facility; “interruption by physician” was the only distraction type to improve in the new EBD hospital.

ISMP Medication Safety Alert! Acute care edition. June 29, 2023;28(13);1-4.

Hard stops in the electronic medical record prevent continuation of ordering, dispensing, or administering an unsafe medication to a patient. This article presents system-level recommendations to effectively introduce hard stops such as including physicians and pharmacists in decision making to reduce risk of workarounds in the future.
Khan WU, Seto E. J Med Internet Res. 2023;25:e43386.
Artificial intelligence (AI) and machine learning (ML) are emerging as tools to improve patient care, but they are not without risks. This article proposes use of a safety checklist to determine readiness to launch AI technologies, prompting users to consider physical and mental health and economic and social risks and benefits.