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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 45 Results
Krenzischek DA, Card E, Mamaril M, et al. J Perianesth Nurs. 2022;37:827-833.
Patients and caregivers are important partners in promoting safe care. Findings from this cross-sectional study reinforce the importance of patients’ perceived roles in ensuring safe surgery and highlight the importance of patient engagement in mitigating surgical site errors.

Laber-Warren E. MedPage Today. April 5, 2022.

Resident autonomy is an essential component to medical training, but it is not without patient safety risks. This news article highlights situations where resident autonomy should be disclosed to patients (such as instances of overlapping surgeries) and the value of transparency about the role of surgical team members.

ISMP Medication Safety Alert! Acute care edition. October 7, 2021;26(20):1-4.

Production pressure and low staff coverage can result in medication mistakes in community pharmacies. This article shares  errors reported to the ISMP Vaccine Errors Reporting Program and factors contributing to mistaken administration of flu and COVID vaccines. Storage, staffing and collaboration strategies are shared to protect against vaccine mistakes.
Ranum D, Beverly A, Shapiro FE, et al. J Patient Saf. 2021;17:513-521.
This analysis of medical malpractice claims identified four leading causes of anesthesia-related claims involving ambulatory surgery centers – dental injuries, pain, nerve damage, and death. The authors discuss the role of preoperative risk assessment, use of routine dental and airway assessment, adequate treatment of perioperative pain, and improving communication between patients and providers.
Liese KL, Davis-Floyd R, Stewart K, et al. Anthropol Med. 2021;28:188-204.
This article draws on interviews and observations to explore medical iatrogenesis in obstetric care. The authors discuss how various factors – such as universal management plans, labor and delivery interventions, and informed consent – contribute to iatrogenic harm and worse perinatal outcomes for racial/ethnic minority patients.
SteelFisher GK, Hero JO, Caporello HL, et al. J Womens Health (Larchmt). 2020;29:1113-1121.
This study explored views, practices, and needs related to patient counseling on medication safety in obstetrics and gynecology. Survey responses from over 500 OB/GYNs indicate opportunities to improve available resources and information sharing, such as developing new tools to communicate about teratogenic medications and pregnancy-safe over-the-counter medications and dietary supplements.
Abrams EM, Shaker M, Oppenheimer J, et al. J Allergy Clin Immunol Pract. 2020;8:2474-2480.e1.
This article discusses the challenges COVID-19 poses for shared decision making (such as physical distancing and health service reallocation, communicating uncertainty, delivering allergy/immunology care) and opportunities to evolve incorporation of shared decision making into clinical practice during and after the pandemic.
WebM&M Case December 18, 2019
A 63-year-old woman with hematemesis was admitted by a 2nd year medical resident for an endoscopy. The resident did not spend adequate time discussing her code status and subsequently, made a series of errors that failed to honor the patient’s preferences and could have resulted in an adverse outcome for this relatively healthy woman.
Meisenberg B, Zaidi S, Franks L, et al. J Hosp Med. 2019;14:716-718.
Advanced Directives (AD) and Physician Orders for Life-Sustaining Therapy (POLST) are intended to improve end-of-life care by ensuring that patient's wishes are honored by health care providers. This perspective presents two cases in which preventable errors allowed for the use of unwanted life-sustaining therapies. Root cause analyses for these cases found that haste, inadequate communication, EMR discrepancies, knowledge deficits contributed to these errors. 
Shoemaker SJ, Brach C, Edwards A, et al. Jt Comm J Qual Patient Saf. 2018;44:343-352.
The process of informed consent is designed to ensure that patients fully understand risks, benefits, and alternatives when receiving certain treatments. In this mixed-methods study, researchers examined the impact of two Agency for Healthcare Research and Quality informed consent training modules across four hospitals.
Siracuse JJ, Benoit E, Burke J, et al. Jt Comm J Qual Patient Saf. 2014;40:126-133.
Written consent forms often introduce issues related to legibility and completeness. A Web-based system for booking elective surgical procedures improved the rate of obtaining and documenting informed consent in a community hospital system.
WebM&M Case February 1, 2012
An elderly man hospitalized with multiple medical conditions decided (with his family's blessing) on a DNR/DNI order. Following treatment, the patient was discharged home. Just days later a paramedic transporting the patient to the emergency department asked the family about advanced directives and they requested that "everything be done."
WebM&M Case December 1, 2011
A patient with Guillain-Barré syndrome received more than the recommended number of plasmapheresis treatments. When the ordering physicians were asked why so many treatments were given, they both responded that the patient was improving so they felt that more treatments would help him recover even more.
Barrios L, Tsuda S, Derevianko A, et al. Surg Endosc. 2009;23:2535-42.
In this study of simulated cholecystectomies, surgical residents felt ill-trained to disclose both complications (common bile duct injury) and serious incidental findings (gallbladder cancer) encountered during a cholecystectomy. Most concerning, a large proportion of residents did not adequately describe potential complications when obtaining informed consent.
Werner RM, McNutt RA. JAMA. 2009;301.
The Leapfrog Group has been a major driver of patient safety efforts—more than 1000 hospitals have committed to implementing its recommendations for computerized provider order entry, intensivist coverage for critically ill patients, evidence-based referral for certain diagnoses, and implementation of the National Quality Forum's (NQF) Safe Practices. A prior study found that hospitals that had implemented at least one Leapfrog practice tended to provide higher quality of care for specific diagnoses. However, in this study, adoption of the NQF safe practices did not correlate with reduced inpatient mortality. The authors note that many hospitals could score highly on the Leapfrog Hospital Survey but not fully implement or consistently follow safety recommendations, as the survey only measures a hospital's self-reported implementation of safety practices.