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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 36 Results

Agency for Healthcare Research and Quality.

Telemedicine efforts harbor both risk and reward to patients and providers. The AHRQ Safety Program for Telemedicine is a national effort to develop and implement a bundle of evidence-based interventions designed to improve telemedicine care in two settings—the cancer diagnostic process and antibiotic use. To test the bundle of interventions, the program will involve two cohorts of healthcare professionals who utilize telemedicine as a care delivery model. It is an 18-month program, beginning in June 2023, that seeks to improve the cancer diagnostic process for patients who receive some or all of their care through telemedicine. Recruitment webinars start in late January and run through early May 2023; the antibiotic use cohort will begin recruitment in December 2023. 
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.  

National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2022. 

Diagnostic errors remain an ongoing challenge in many medical specialties, including oncology. This workshop reviewed the evidence base examining challenges in cancer diagnosis, discussed suggestions for improvement in the field, and looked toward a safer future for cancer patients.
Raghuram N, Alodan K, Bartels U, et al. Virchows Archiv. 2021;478:1179-1185.
Autopsies are an important tool for identifying diagnostic errors. This retrospective study of 821 pediatric cancer deaths found that 10% had a major diagnostic discrepancy between antemortem and postmortem diagnoses. These discrepancies primarily consisted of missed infections, missed cancer diagnoses, and organ complications.
Wyatt KD, Freedman EB, Arteaga GM, et al. Cancer Med. 2020;9:8844-8851.
Chemotherapy medications often have complex dosing which can lead to prescribing errors. This article describes the use of simulation-based training to improve pediatric hematology/oncology providers’ ability to identify and mitigate common chemotherapy ordering errors. The authors suggest that simulation-based training can serve as an alternative to systems-based electronic health record (EHR) improvements.
Alexander M, Jupp J, Chazan G, et al. J Oncol Pharm Pract. 2020;26:1225-1229.
From the perspective of both developed and developing nations, the authors of this commentary discuss how the COVID-19 pandemic has impacted access to and delivery of cancer treatment and how the global pharmacy community is responding, including changing and expanding scopes of practice.
Weingart SN, Nelson J, Koethe B, et al. Cancer Med. 2020;9:4447-4459.
Using a cohort of adults diagnosed with breast, colorectal, lung or prostate cancer, this study examined the relationship between oncology-specific triggers and mortality. It found that patients with at least one trigger had a higher risk of death than patients without a trigger; this association was strongest for nonmetastatic prostate cancer and nonmetastatic colorectal cancer. Triggers most commonly associated with increased odds of mortality were bacteremia, blood transfusion, hypoxemia and nephrology consultation. These findings support the validity of cancer-specific trigger tool but additional research is needed to replicate these findings.
Rabin RC. Faced with a drug shortfall, doctors scramble to treat children with cancer. New York Times. October 14, 2019.
Drug shortages create potential complexities in drug therapy that can result in unsafe medication use. This story examines a vincristine shortage affecting pediatric patients.  Systemic factors contributing to the problem discussed include medications produced by a single supplier and workarounds when supplies are threatened. 
Carberry AR, Hanson K, Flannery A, et al. Clin Pediatr (Phila). 2017;57*1(:11-18.
Missed or delayed cancer diagnoses can lead to delays in treatment and worse outcomes. This retrospective cohort study of new pediatric cancer patients found that there were diagnostic delays or errors in 28% of cases. The authors suggest that multiple visits for the same complaint should raise concerns about diagnostic accuracy.
Walsh K, Ryan J, Daraiseh N, et al. Oncology. 2016;91:231-236.
Medication errors and nonadherence to medications contribute to increased use of health care resources. This study sought to better characterize the relationship between medication errors and nonadherence in children on oral chemotherapy. Researchers found both to occur in the same population and suggest that family and health system interventions could help mitigate errors and nonadherence in pediatric patients with cancer.
Unguru Y, Fernandez C, Bernhardt B, et al. J Natl Cancer Inst. 2016;108:djv392.
Drug shortages have become increasingly common in recent years, especially in the United States. Some pediatric chemotherapeutics have frequently been in short supply, posing serious risks to patient safety. This commentary describes an ethical framework developed by a multidisciplinary group of experts and a panel of peer consultants. The framework seeks to guide clinicians' decision-making around allocating life-saving chemotherapies and associated drugs for children with cancer. The authors describe methods for managing shortages by reducing waste. The guideline also provides clear reasoning for actual prioritization across and within common pediatric cancers during a drug shortage. For example, in cases where shortages lead to the inability to provide the standard of care for some children, the authors propose emphasizing curability and prognosis in determining who is likely to have the most benefit. In 2013, the FDA released a strategic plan for preventing drug shortages, but the problem has continued largely unabated.
Looper K, Winchester K, Robinson D, et al. J Pediatr Oncol Nurs. 2016;33:165-72.
Chemotherapy is a high-risk treatment that requires specific safety protocols. This commentary describes an effort that successfully determined and implemented best practices for chemotherapy administration in children. The intervention included an interdisciplinary program that reviewed current processes and evidence, utilized quality improvement tools, and established standardized techniques, exact times, and consistent documentation to augment safety associated with use of this medication.
Call RJ, Burlison JD, Robertson JJ, et al. J Pediatr. 2014;165:447-52.e4.
To investigate the utility of a trigger tool in detecting adverse drug events (ADEs) in pediatric hematology and oncology patients, this study compared the tool with a voluntary reporting system. Implementation of the trigger tool led to inclusion of many cases that were not ADEs (false positives). In contrast, voluntary reporting did not identify all ADEs that were found using the trigger tool, implying under-reporting. These results reinforce prior research suggesting that multiple detection methods are needed to comprehensively detect ADEs. The authors advocate for triggers to be refined according to patient population and hospital setting to augment their usefulness. A previous AHRQ WebM&M perspective discusses the role of trigger tools in identifying ADEs and measuring patient safety.
Mueller BU. Pediatr Blood Cancer. 2014;61:966-9.
Children with cancer are particularly vulnerable to medication errors. This review describes how to enhance safe medication use in pediatric oncology through establishing a safety culture, integrating high reliability principles, and teamwork training.
Dhamija M, Kapoor G, Juneja A. J Pediatr Hematol Oncol. 2014;36:e412-5.
The significant toxicity and individualized dosing required for chemotherapy may lead to serious medication errors. Medication administration protocols and checklists are often employed for administering chemotherapy. This observational study within a tertiary hospital in urban India found that errors occurred in 13.6% of observed medication administrations, and the majority of errors were not intercepted. The harm associated with these errors led to increased need for monitoring in some cases, but no permanent harm or death. A past AHRQ WebM&M perspective described a widely known incident of chemotherapy medication overdose.