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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 43 Results
Newman-Toker DE, Nassery N, Schaffer AC, et al. BMJ Qual Saf. 2023;Epub Jul 17.
Previous research has found that three diseases (vascular events, infections, and cancers) account for approximately 50% of all serious misdiagnosis-related harm. Based on a sample of 21.5 million US hospital discharges, the authors estimated that 795,000 adults in the US experience serious misdiagnosis-related harm (permanent morbidity or mortality) attributable to these three disease categories each year.
Black GB, Boswell L, Harris J, et al. Prim Health Care Res Dev. 2023;24:e26.
Delayed cancer diagnosis is a major contributor to suboptimal outcomes and malpractice claims. In this review, factors contributing to delayed diagnosis of blood cancers are explored. Initial delays resulted from patients’ non-specific symptoms such as fatigue and symptoms that came and went. After seeking care, factors contributing to delayed diagnosis include seeing a locum general practitioner, being Black or a woman, and having multiple chronic conditions.

Lovelace B, Jr, Kopf M. NBC. April 11, 2023.

Shortages of life-saving cancer drugs have been a problem for many years and were exacerbated by the COVID-19 pandemic. This news article reports that low profitability of manufacturing generic drugs contributes to this shortage. Until these cancer drugs are available, many patients will receive no treatment, or treatment that is less than ideal.
Trivedi A, Ajitsaria R, Bate T. Arch Dis Child Educ Pract Ed. 2022;108:115-119.
Pediatric patients are at particularly high risk for medication errors. This article describes the STAMP initiative (Safe Treatment and Administration of Medicine in Pediatrics) which aims to reduce pediatric inpatient prescribing and administration errors. The authors summarize the STAMP interventions originally implemented in 2017 and discuss the new interventions implemented during the COVID-19 pandemic (between July 2020 and August 2021), which led to sustained reductions in prescribing errors.
Wong CI, Vannatta K, Gilleland Marchak J, et al. Cancer. 2023;129:1064-1074.
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.

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. 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 KE, 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.