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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 405 Results
WebM&M Case March 15, 2023

The cases described in this WebM&M reflect fragmented care with lapses in coordination and communication as well as failure to appropriately address medication discrepancies. These two cases involve duplicate therapy errors, which have the potential to cause serious adverse drug events.

Solares NP, Calero P, Connelly CD. J Nurs Care Qual. 2023;38:100-106.
Falls in inpatient healthcare settings are a common patient safety event. This study including 201 older inpatient adults evaluated the relationship between the Johns Hopkins Fall Risk score and patient perceptions of fall risk. Researchers found that the greater the patient’s confidence in their ability to perform a high fall-risk behavior, the lower the fall-risk score.
Urgent care clinics offer services to a wide patient base that increase the complexities of medication prescribing and administration. Safety culture, process, and structural factors are discussed as avenues to increase safety in this unique ambulatory setting. The piece highlights the importance of education, rules, and storage procedures to ensure safe medication administration.
Oksholm T, Gissum KR, Hunskår I, et al. J Adv Nurs. 2023;Epub Feb 10.
Transitions of care can increase risks for patient safety events. This systematic review examined the effectiveness of interventions aimed to increase patient safety during transitions of care between the hospital and home. The authors identified several interventions from previously published studies which increased patient safety and/or patient satisfaction and identified factors that contribute to effective transitions of care (i.e., nurse follow-up, pre-discharge patient education, and contact with local healthcare services).
Townshend R, Grondin C, Gupta A, et al. Jt Comm J Qual Patient Saf. 2023;49:70-78.
Ensuring patients have an understanding of their diagnoses and care plan is a critical component of patient engagement and can improve safety. Using semi-structured phone interviews and electronic health record (EHR) review, this study examined patient understanding about their inpatient care and discharge plan. Although the majority of patients (>90%) felt confident in their knowledge of their diagnosis and treatment plan, chart review indicated that only 43% to 64% correctly recalled details about their diagnosis, treatment, post-discharge treatment plan, and medication changes.
Balestracci B, La Regina M, Di Sessa D, et al. Intern Emerg Med. 2023;18:275-296.
The COVID-19 pandemic extended face-masking requirements from healthcare providers to the general public and patients. This review summarizes the challenges mask wearing poses to the general public. Challenges include discomfort, communication issues, especially for people with hearing loss, and skin irritation. Despite these issues, the authors state the benefits outweigh the risks of masks and appropriate education may improve mask use.
Wong CI, Vannatta K, Gilleland Marchak J, et al. Cancer. 2023;Epub Jan 27.
Children with complex home care needs, such as children with cancer, are particularly vulnerable to medication errors. This longitudinal study used in-home observations and chart review to monitor 131 pediatric patients with leukemia or lymphoma for six months and found that 10% experienced adverse drug events due to medication errors in the home and 42% experienced a medication error with the potential for harm. Failures in communication was the most common contributing factor. Findings underscored a critical need for interventions to support safe medication use at home. Researchers concluded that improvements addressing communication with and among caregivers should be co-developed with families and based on human-factors engineering.
WebM&M Case February 1, 2023

These cases describe the rare but dangerous complication of hematoma following neck surgery. The first case involves a patient with a history of spinal stenosis who was admitted for elective cervical discectomy and cervical disc arthroplasty who went into cardiopulmonary arrest three days post-discharge and could not be intubated due to excessive airway swelling and could not be resuscitated. Autopsy revealed a large hematoma at the operative site, causing compression of the upper airway, which was the suspected cause of respiratory and cardiac arrest.

Curated Libraries
January 19, 2023
The Primary-Care Research in Diagnosis Errors (PRIDE) Learning Network was a Boston-based national effort to improve diagnostic safety. Hosted by the State of Massachusetts’ Betsy Lehman Center, it was led by the Harvard Brigham and Women’s Center for Patient Safety Research and Practice with funding from the Gordon and Betty Moore Foundation. ...
Alqahtani N. J Eval Clin Pract. 2022;28:1037-1049.
Insulin-related errors result in nearly 100,000 emergency department visits annually in the United States, with 30% resulting in hospitalization. It is unclear if published guidelines and strategies for reducing these errors have been effective; therefore, this review sought to identify interventions to reduce insulin errors in home and hospital settings. Three themes emerged: technology, education, and policy. Understanding these findings may help clinicians and patients to decrease insulin administration errors and help researchers develop and evaluate future studies targeting insulin-related errors.

Boston, MA; Institute for Healthcare Improvement: December 2022.

Systemic efforts to improve health equity support patient safety. This announcement highlights an initiative for collective work to address four areas of effort to reduce inequity in health care: access, workforce, social and structural drivers, and quality and safety.

ISMP Medication Safety Alert!: Acute Care Edition. December 1, 2022;27(24):1-3.

Look-alike medications are vulnerable to wrong route and other use errors. This article examines the potential for mistaken application of ear drops into eyes. Strategies highlighted to reduce this error focus on storage, dispensing, administration, and patient education.

Healthcare Excellence Canada. 2022.

After a patient safety incident, effective discussions are critical for healing and improvement. This website houses collections of materials to support constructive communication should a failure or near-miss occur. There are two distinct sections of materials: one for established healthcare professionals, and another for patients, students, and caregivers.
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.  

Meyer DB. Boca Raton, FL: Universal Publishers; 2022. ISBN:‎ 9781627344067

Individual commitment to patient safety can motivate change. This book highlights an advocacy action by a patient safety leader to generate awareness, engagement, and action using personal, professional, and patient stories of error.
Tubic B, Finizia C, Zainal Kamil A, et al. Nurs Open. 2023;10:1684-1692.
Interventions to increase patient engagement in safety are receiving increasing attention. In this study, patients were given a safety leaflet containing information about the patient can avoid adverse events during their hospital stay. Participants were overall satisfied about receiving information about their care but noted a lack of communication between healthcare personnel and patients regarding the safety leaflet.
Curated Libraries
October 10, 2022
Selected PSNet materials for a general safety audience focusing on improvements in the diagnostic process and the strategies that support them to prevent diagnostic errors from harming patients.
Reeve J, Maden M, Hill R, et al. Health Technol Assess. 2022;26:1-148.
Deprescribing is a strategy to reduce potential harms associated with polypharmacy. This scoping review synthesized the evidence about how physicians and patients feel about deprescribing and how deprescribing can be done safely. Shared decision making was identified as an essential component for building trust in the process and for keeping it patient-centered.
Whatley C, Schlogl J, Whalen BL, et al. Jt Comm J Qual Patient Saf. 2022;48:521-528.
Newborn falls or drops are receiving increasing attention as a patient safety issue. This article discusses a quality improvement initiative launched at one hospital aimed to decrease newborn falls through new parent education materials, a nursing risk assessment tool, and standardized reporting system. Three years after implementation, the hospital achieved one year without any newborn falls and there were no fall-related injuries over the three-year period.