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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 - 13 of 13 Results

PAR-23-120. Bethesda, MD: National Institutes of Health; March 7, 2023

Approaching diagnosis as a team activity is seen as a key approach to diagnostic effectiveness. This notice highlights a funding opportunity to launch Diagnostic Centers of Excellence to improve diagnosis of undiagnosed and unknown disease and research to inform improvement.

National Institutes of Health.  August 11, 2022. RFA-HD-23-035.

Maternity care is increasingly being recognized as vulnerable to implicit biases and social inequities. This funding announcement aims to support initiatives that promote equity as a primary component of efforts to study preventable maternal harm in a variety of disadvantaged and ethnic populations. The application process is now closed.
Boserup B, McKenney M, Elkbuli A. Am J Emerg Med. 2020;38:1732-1736.
Using data from the CDC’s National Center for Immunization and Respiratory Diseases, this study assessed changes in Emergency Department (ED) visits due to COVID-19. The average number of ED visits during a four-week period at the height of the pandemic was significantly less than in the four weeks prior to the pandemic. Patient education efforts should focus on the importance of prompt medical intervention for acute conditions (such as stroke or heart attack) and telehealth services for non-acute conditions.    
Jayaprakash N, Chae J, Sabov M, et al. Mayo Clin Proc Innov Qual Outcomes. 2019;3:327-334.
Deviations or variations in diagnostic fidelity, including diagnostic errors and delays, can lead to serious adverse events or death, yet measurement tools and reporting processes for ensuring diagnostic fidelity are underdeveloped. This single-site retrospective study found that these errors and delays can be reliably identified using EMR data, and that variations in diagnostic fidelity are linked to increased morbidity and mortality. 
Splinter K, Adams DR, Bacino CA, et al. New Engl J Med. 2018;379:2131-2139.
Improving diagnosis remains a major focus within patient safety. For patients with rare diseases, diagnosis can often be delayed. Established in 2014 and funded by the National Institutes of Health, the Undiagnosed Diseases Network (UDN) applies a multidisciplinary approach to the most challenging diagnostic cases. Over a 20-month period, 601 out of 1519 patient cases were accepted by the UDN for evaluation. The authors report that of the 382 patients who underwent a complete evaluation, a diagnosis was identified in 132 patients.
Chou R, Turner JA, Devine EB, et al. Ann Intern Med. 2015;162:276-86.
Opioid medications are associated with increased risk of adverse drug events, including overdoses. This systematic review found that evidence supporting the use of long-term opioid therapy for chronic pain is lacking.
The Clinical Center Working Group Report to the Advisory Committee to the Director, National Institutes of Health. Bethesda, MD; National Institutes of Health; April 2016.
This publication outlines system problems at a large research institution that could compromise patient safety, including supervisors' failure to address staff-reported concerns, prioritization of research productivity over safety, insufficient processes for reporting and tracking problems, and fragmented accountability for ensuring quality and safety at the institution.
Donaldson N, Aydin C, Fridman M, et al. J Healthc Qual. 2014;36:58-68.
This cross-sectional study presents data collected from the Collaborative Alliance for Nursing Outcomes benchmarking registry. In this convenience sample, nurses deviated from medication administration safe practices approximately 11% per encounter, and administration errors occurred 0.32% per encounter. Distractions or interruptions accounted for nearly one-fourth of the safe practice deviations.
Eunice Kennedy Shriver National Institute of Child Health and Human Development; NICHD; National Institutes of Health; NIH.
This dual-component funding program will support collaborative research and project development projects that explore strategies to reduce medical error in both routine hospital settings and intensive care units. This funding cycle has an expiration due date of September 8, 2021.