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 1278 Results

Reducing errors resulting from commonly missed chest radiography findings.

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Gefter WB, Hatabu H. Chest. 2023;163:634-649.

Cognitive bias, fatigue, and shift work can increase diagnostic errors in radiology. This commentary recommends strategies to reduce these errors in diagnostic chest radiography, including checklists and improved technology (e.g., software, artificial intelligence). In addition, the authors offer practical step-by-step recommendations and a sample checklist to assist radiologists in avoiding diagnostic errors.

Implementation of ED I-PASS as a standardized handoff tool in the pediatric emergency department.

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Yanni E, Calaman S, Wiener E, et al. J Healthc Qual. 2023;45:140-147.

I-PASS is a structured handoff tool that aims to improve communication and reduce adverse events during transitions of care. This article describes the implementation of a modified I-PASS tool for use in the emergency department (ED I-PASS) to improve transitions of care between pediatric emergency medicine physicians. Implementation of ED I-PASS decreased the perceived loss of key patient information during transitions of care (from 75% to 37.5%).

Diagnostic errors in musculoskeletal oncology and possible mitigation strategies.

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Flemming DJ, White C, Fox E, et al. Skeletal Radiol. 2023;52:493-503.

Radiologic diagnostic errors can result in delayed or unnecessary treatment. This paper describes five types of cognitive biases, with accompanying case study and images, that result in misdiagnosis. Both individual education and system-level solutions are described.

Structural racism in behavioral health presentation and management.

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Rainer T, Lim JK, He Y, et al. Hosp Pediatr. 2023;13:461-470.

Structural racism and implicit biases can affect clinical judgement and impede the delivery of effective mental health care. Based on a case of an adolescent Black girl navigating through the pediatric behavioral health system, this article discusses how structural racism and health disparities in behavioral health care contributed to misdiagnosis and poor care. The authors outline several actions at the structural, institutional, and interpersonal levels to address racism’s impact on pediatric mental and behavioral healthcare.

Systematic literature review on the effectiveness and safety of paediatric hospital-at-home care as a substitute for hospital care.

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Detollenaere J, Van Ingelghem I, Van den Heede K, et al. Eur J Pediatr. 2023;Epub Apr 3.

The hospital-at-home (HAH) model allows patients to receive hospital-level care in their homes. This systematic review identified 25 articles (18 interventions) comparing outcomes of pediatric HAH care to standard in-hospital care. Hospital at home was not associated with increased hospital readmissions or adverse events. However, the quality of the studies was low to very low, and additional high-quality research is required.

Non-accidental Injuries in Infants Attending the Emergency Department.

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Farnborough, UK: Healthcare Safety Investigation Branch; April 2023.

Misattribution of child maltreatment injuries can be a serious misdiagnosis affecting families and patients. This report analyzes ten safety incident reports from across the British National Health Service to explore how non-accidental injury was missed. Themes identified as contributing to the problems include lack of information sharing, inconsistent guidance, and emergency department care demands.

Types of diagnostic errors reported by paediatric emergency providers in a global paediatric emergency care research network.

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Mahajan P, Grubenhoff JA, Cranford J, et al. BMJ Open Qual. 2023;12:e002062.

Missed diagnostic opportunities often involve multiple process breakdowns and can lead to serious avoidable patient harm. Based on a web-based survey of 1,594 emergency medicine physicians, missed diagnostic opportunities most frequently occur in children who present to the emergency department with undifferentiated symptoms (e.g., abdominal pain, fever, vomiting) and often involve issues related to the patient/parent-provider interaction, such as misinterpreting patient history or inadequate physical exam.

Error disclosure in neonatal intensive care: a multicentre, prospective, observational study.

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Passini L, Le Bouedec S, Dassieu G, et al. BMJ Qual Saf. 2023;Epub Mar 14.

Medical errors in the neonatal intensive care unit (NICU) are common and can result in significant patient harm. This prospective observational study conducted at 10 NICUs in France found that approximately 41% of the 1,822 errors (among 1,019 patients) were disclosed to the patient’s parents. Providers cited parental absence (i.e., the error occurred overnight) and perceived lack of serious consequences for the infant as the most frequent reason for non-disclosure.

The effect of documenting patient weight in kilograms on pediatric medication dosing errors in emergency medical services.

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Ward CE, Taylor M, Keeney C, et al. Prehosp Emerg Care. 2023;27:263-268.

Weight-based calculation errors and lack of weight documentation can lead to medication errors in pediatric patients. This analysis of Maryland emergency medical services (EMS) data including children who received a weight-based medication found that weight documentation was associated with a small but significantly lower rate of medication dose errors, particularly among infants and for epinephrine and fentanyl doses.

Medical line entanglement: the unspoken patient safety hazard of medical devices.

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Larimer C, Sumner V, Wander D. Nutr Clin Pract. 2023;Epub Apr 19.

Medical lines, such as intravenous (IV), oxygen, or feeding tubes, provide lifesaving support but may also pose safety threats. Following a 2022 Food and Drug Administration safety communication regarding risk of strangulation by feeding tubes, researchers sought to determine if pediatric healthcare providers and caregivers were aware of the risk of medical line entanglement, and what, if any, type of education was provided to reduce the risk. Most providers were aware of the risk of entanglement, and 90% of caregivers reported their child had become entangled. However, less than 10% of caregivers received training to prevent such entanglements. Numerous comments from caregivers are provided, describing instances of entanglements and strategies they’ve used to prevent it.

Improving Diagnostic Safety and Quality

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Perspective on Safety April 26, 2023

Throughout 2022, AHRQ PSNet has shared research that elucidates the complex nature of misdiagnosis and diagnostic safety. This Year in Review explores recent work in diagnostic safety and ways that greater safety may be promoted using tools developed to improve diagnostic practices.

The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department.

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WebM&M Case April 26, 2023

This case involves a procedural sedation error in a 3-year-old patient who presented to the Emergency Department with a left posterior hip dislocation. The commentary summarizes the indications and risks of procedural sedation in non-surgical settings and highlights the value of implementing system-wide safety protocols and practices to prevent medication administration errors during high-risk procedures.

Cancer drug shortages are creating dire circumstances for some patients.

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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.

Safety Risk of Air Embolus Associated with Central Venous Catheters Used for Haemodialysis Treatment.

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Farnborough, UK: Healthcare Safety Investigation Branch. March 2023.

Patients receiving hemodialysis are at risk of complications, including air embolus. This report describes how unfamiliar equipment and lack of standardized training contributed to the death of a dialysis patient due to air embolus. Safety recommendations include changes in medical education on how to handle uncertainty in clinical settings and amending dialysis guidelines to include risk of air embolus associated with unclamped central venous catheters.

STAMP: a 5-year project to reduce paediatric prescribing errors.

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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.

Preventing home medication errors.

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Shaikh U, van der List L, Blumberg D. Kids Considered. March 27, 2023.

Medication administration at home can be problematic especially for parents caring for children. This podcast highlights common reasons for medication mistakes at home and how they can be avoided. Simple steps such as not using regular spoons as methods of delivering liquid medications are highlighted.

Improving medication safety in a paediatric hospital: a mixed-methods evaluation of a newly implemented computerised provider order entry system.

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Liang MQ, Thibault M, Jouvet P, et al. BMJ Health Care Inform. 2023;30(1):e100622.

Computerized provider order entry (CPOE) systems are widely used and can help prevent medication administration errors. This mixed-methods study examined the impact of CPOE on medication safety in the pediatric department at one Canadian hospital. Researchers found that most errors occurred during the medication administration step rather than the prescribing step. The researchers also observed a non-statistically significant decrease in medication errors overall, which was primarily attributed to significant improvements in errors during order acknowledgement, transmission, and transcription.

Effects of racial bias in pulse oximetry on children and how to address algorithmic bias in clinical medicine.

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Gray KD, Subramaniam HL, Huang ES. JAMA Pediatr. 2023;177:459-460.

Previous research has identified racial and ethnic discrepancies in pulse oximetry measurement which can lead to delays in diagnosis or treatment. This editorial discusses racial and ethnic biases in clinical algorithms and devices and two emerging approaches – photoacoustic imaging and polarized light oximetry – that have potential to address the racial and ethnic biases in pulse oximetry.

Making polypharmacy safer for children with medical complexity.

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Feinstein JA, Orth LE. J Pediatr. 2023;254:4-10.

Children with medical complexity (CMC) frequently take multiple medications, often from multiple prescribers. This commentary describes the particular vulnerabilities CMC face throughout the medication use cycle, along with ways for the prescriber and system to mitigate the risks of polypharmacy.

Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue.

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WebM&M Case March 29, 2023

This case describes a 13-year-old girl who presented to several health care providers with typical symptoms, physical signs, and early laboratory findings suggestive of adrenal insufficiency (AI) yet the diagnosis was delayed for several months due to diagnostic biases. After she suffered a sudden cardiac arrest during a visit to her local emergency department and was airlifted to a tertiary care facility, she was found to be in adrenal crisis secondary to Addison’s disease.

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