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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 427 Results
Wu AW, Papieva I, Sheridan S, et al. J Patient Saf Risk Manag. 2023;28:147-152.
True partnership with patients and families in safety work is an important yet elusive goal. This commentary outlines elements supporting engagement as part of an ambitious global plan and awareness campaign to ensure medical error reduction efforts are fully informed and enriched through the application of the patient and family experience in health care.
DeCoster MM, Spiller HA, Badeti J, et al. Pediatrics. 2023;Epub Sep 18.
Data from the National Poison Data System is useful for describing characteristics and trends of out-of-hospital medication errors. This retrospective study describes trends in therapeutic errors involving attention deficit/hyperactivity disorder (ADHD) medications as reported to poison control centers in the United States. From 2000 to 2021, errors increased by 300%, with more than half classified as "inadvertently took or was given medication twice." Although no deaths were reported and less than 5% resulted in moderate or major medical outcomes, increased patient and caregiver education and child-resistant medication containers are needed.
Joint Commission.
The Speak Up campaign provides sets of materials to enable patients and families to engage in making their health care experiences as safe as possible. Topics covered include safe surgery, pain management, medication safety, and most recently, how preventive care helps to keep patients healthy and out of the hospital. Each topical package includes infographics, videos, and distribution guidance. Some written materials are available in Spanish.

Graedon T. People’s Pharmacy.  Show 1355. September 8, 2023.

Misdiagnosis continues to impact the safety of health care. This podcast with David Newman-Toker discusses foundational issues that detract from diagnostic safety and examines how teamwork, training, technology, tuning can make the process more reliable. Strategies for patients to play a role in their diagnostic process are also discussed.
Mikkelsen TH, Søndergaard J, Kjaer NK, et al. BMC Geriatr. 2023;23:477.
Older adults taking 5 or more medications daily (i.e., polypharmacy) face numerous challenges to taking them safely. In this study, patients, caregivers, and clinicians describe methods to taking medications safely, difficulties they face, and ways prescribers and pharmacists can assist patients. Medication reviews, a common strategy to ensure safe polypharmacy, were requested by patients to clear up confusion around generics, timing, limitations, and side effects.
de Dios JG, Lopez-Pineda A, Juan GM-P, et al. BMC Pediatr. 2023;23:380.
Children are at-risk for medication errors in the home setting, but no single database exists to collect these errors. This study compared parent and pediatrician perspectives on home medication safety for children aged 14 and under. Approximately 80% of pediatricians thought parents consulted the internet for information about their child's care and medications, and an equal percent of parents reported consulting their healthcare provider. Both groups reported lack of parental knowledge as the main contributor to medication errors, and most pediatricians supported the idea of a mechanism for collecting parent-reported errors and a learning system to support family engagement in medication error prevention.

HealthJournalism.org. Columbia, MO: Association of Health Care Journalists; 2010-2023.

The role media plays in raising awareness of patient safety issues in a timely and appropriate manner is consequential. This series instructs writers to communicate on medical error and quality topics in a high-quality professional style with discernment of the content being reported. Series contributions include discussions on medical error statistics and outpatient surgery rankings.
Bittencourt NCC de M, Duarte S da CM, Marcon SS, et al. Healthcare (Basel). 2023;11:2030.
Adverse events in palliative care can include inappropriate pain management, preventable hospital (re)admissions, falls, and pressure injuries. This paper outlines ways palliative care is not always received timely, the uniqueness of patient safety within palliative care, and how to raise awareness of both of these issues for healthcare providers, educators, and patients and families.

Salamon M. Harvard Women's Health Watch. August 1, 2023

Patients can help minimize the potential for adverse events while in the hospital. Actions such as working with a care partner, tracking medications, and recognizing fall risks can protect against mistakes causing harm.
McMullen S, Panagioti M, Planner C, et al. Health Expect. 2023;26:2064-2074.
Caregivers and family members offer a unique perspective on patient safety. In this study, patient and caregiver stakeholders outlined the safety threats affecting patients discharged from mental health services and the well-being of caregivers as well as potential solutions. Participants highlighted approaches to improve caregiver involvement, patient and caregiver wellness and education, and the policy and system environments.

Jaklevic MC. HealthJournalism.org. July 27, 2023.

Published rates of medical errors continue to draw attention to gaps in care that demonstrate the need for continued effort toward development and implementation of system-focused safety solutions. This article discusses the importance of representing error statistics responsibly and offers recommendations to ensure accurate representations of the challenges facing safe care delivery.
Rosa R, Sposato K, Abbo LM. AORN J. 2023;117:300-311.
Preventing surgical site infections remains a persistent challenge to patient safety. This article outlines strategies to prevent surgical site infections during the perioperative period and the roles that infection surveillance, infection prevention bundles, and a culture of safety play a substantial role in decreasing the rate of surgical site infections.

Board on Health Care Services, National Academies of Science, Engineering, and Medicine. Arnold and Mabel Beckman Center, Irvine, CA. July 27, 2023. 

Misdiagnosis during pregnancy can have tragic results for both the pregnant person and infant. This free workshop will discuss current challenges in maternal diagnostic excellence, identifications of knowledge gaps, and strategies to decrease maternal disparities. The workshop is open to the public can be attended in-person or virtually.
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.
Lekman J, Lindén E, Ekstedt M. Scand J Caring Sci. 2023;Epub May 24.
Risk reduction in home health faces unique challenges. In this study of registered nurses providing home health, challenges included finding a balance between the patient's autonomy and ensuring a safe environment, building relationships with the patient and family, and gaps between resources and requirements.
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.
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.

Sheridan S. Turn on the Lights. Institute for Healthcare Improvement.  May 2023

Patient engagement is an important component in patient safety. This episode from the Turn on the Lights podcast (hosted by Institute for Healthcare Improvement leaders Don Berwick, MD and Kedar Mate, MD) features a discussion with Sue Sheridan from Patients for Patient Safety US about the importance of involving patients and patient perspectives in the development of patient safety solutions.