Skip to main content

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.

Search All Content

Search Tips
Save
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Search By Author(s)
Additional Filters
Approach to Improving Safety
Displaying 1 - 20 of 727 Results
Bell SK, Harcourt K, Dong J, et al. BMJ Qual Saf. 2023;Epub Aug 21.
Patient and family engagement is essential to effective and safe diagnosis. OurDX is a previsit online engagement tool to help identify opportunities to improve diagnostic safety in patients and families living with chronic conditions. In this study, researchers implemented OurDX in specialty and primary care clinics at two academic healthcare organizations and examined the potential safety issues and whether patient/family contributions were integrated into the post-visit notes. Qualitative analysis of 450 OurDX reports found that participants contributed important information about the diagnostic process. Participants with diagnostic concerns were more likely to raise concerns about the diagnostic process (e.g., access barriers, problems with tests/referrals, communication breakdowns), which may represent diagnostic blind spots.

Grubenhoff JA, Cifra CL, Marshall T, et al. Rockville, MD: Agency for Healthcare Research and Quality; September 2023. AHRQ Publication No. 23-0040-5-EF.

Unique challenges accompany efforts to study and reduce diagnostic error in children. This issue brief discusses addressing obstacles associated with testing and care access limitations that affect diagnosis across a variety of pediatric care environments. It also provides recommendations for building capacity to advance pediatric diagnostic safety. This issue brief is part of a series on diagnostic safety.

Rockville, MD: Agency for Healthcare Quality and Research; August 22, 2023.

The articulation of diagnostic error in the ambulatory setting is emerging. These newly released funding announcements seek proposals that focus on understanding the factors contributing to diagnostic error and strategies to improve diagnostic safety in the ambulatory care environment. The application deadline for both opportunities has passed.
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.
Spinks J, Violette R, Boyle DIR, et al. Med J Aust. 2023;Epub Aug 16.
Medication safety in ambulatory care settings is an area of growing concern. This article describes ACTMed (ACTivating primary care for MEDicine safety), a cluster randomized trial set in Australia which intends to improve medication safety in primary care settings. The ACTMed intervention will use health information technology (e.g., clinical indicator algorithms), guideline-based clinical recommendations, shared decision-making, and financial incentives to reduce serious medication-related harm, medication-related hospitalizations, and death.
Prior A, Vestergaard CH, Vedsted P, et al. BMC Med. 2023;21:305.
System weaknesses (e.g., resource availability, deficiencies in care coordination) threaten patient safety. This population-based cohort study including 4.7 million Danish adults who interacted with primary or hospital care in 2018, found that indicators of care fragmentation (e.g., higher numbers of involved clinicians, more transitions between providers) increased with patient morbidity level. The researchers found that higher levels of care fragmentation were associated with adverse outcomes, including potentially inappropriate prescribing and mortality.
Laster M, Kozman D, Norris KC. Pediatr Clin North Am. 2023;70:725-743.
Structural racism and the resulting negative social determinants of health (SDoH) impact the quality of care that children of color receive. This commentary presents strategies for pediatricians to eliminate structural racism at the system- and organizational-levels such as ensuring access to equitable healthcare facilities, creating an environment of inclusion and respect, and eliminating use of algorithms that include race or ethnicity and result in inequitable treatment.

Bradford A, Goeschel C, Shofer M, et al. Am Fam Physician. 2023;108(1):14-16.

Diagnostic errors are common in the ambulatory environment. This article discusses five tools to help primary care practices implement diagnostic safety improvement strategies. The authors share overarching considerations to support tool implementation including keeping efforts modest and seeing diagnostic safety beyond the clinical realm.
Monkman H, Kuziemsky C, Homco J, et al. Stud Health Technol Inform. 2023;304:39-43.
Implementation challenges can hinder the safety of telehealth. In this study, medical students used Healthcare Failure Modes and Effect Analysis to identify the causes of failures in telehealth and potential prevention strategies. Four categories of failures were identified: technical issues, patient safety, communication, and social and structural determinants.
Sha S, Aleshire M. Health Promot Pract. 2023;24:536-545.
Regular depression screening is recommended for all adults. Using a clinical vignette, the sexuality Implicit Association Test (IAT), and measures of explicit bias, this study examined the relationship of primary care providers' (PCP) bias towards lesbian women and recommendations for depression screening. Providers who recommended screening showed slightly more positive explicit attitudes and slightly lower, though not statistically significant, implicit bias towards lesbian women. However, recommendation rates among all providers were low, at only 38%.
Maras SA. Soc Sci Med. 2023;331:116066.
Intimate partner violence (IPV) victims and survivors frequently access healthcare, but don’t always receive trauma-informed care or referrals to IPV resources. This study asked IPV survivors what patient safety meant to them. They described it as care that contained: 1) compassionate and/or trauma-informed care; 2) physically safe spaces; and/or 3) a connection to social resources. Survivors described ways healthcare providers could improve IPV safety.
Hilario C, Louie-Poon S, Taylor M, et al. Int J Soc Determinants Health Health Serv. 2023;53:343-353.
Structural racism is increasingly recognized as a social determinant of health. This systematic review identified 13 articles on the impact of racism on racialized adolescents. Most articles focused on the impact of racism on healthcare access and utilization, and in general or mental health care. Research into multiple forms of racism (i.e., institutional, interpersonal, internalized) and development and incorporation of robust measures of racism is needed to advance the field.
Khazen M, Sullivan EE, Arabadjis S, et al. BMJ Open. 2023;13:e071241.
Improving diagnostic quality is a patient safety priority. In this study, researchers used audio-recorded encounters, clinical note review, and interviews in order to evaluate a tool assessing key elements of diagnostic quality during clinical encounters. Many elements were reliably included in the clinical note or encounter transcript (e.g., follow-up contingencies, red flags) but other elements were often missing (e.g., psychosocial/contextual information). The researchers found that burnout was more common among physicians recording fewer key diagnostic elements.
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.
Murphy DR, Zimolzak AJ, Upadhyay DK, et al. J Am Med Inform Assoc. 2023;30:1526-1531.
Measuring diagnostic performance is essential to identifying opportunities for improvement. In this study, researchers developed and evaluated two electronic clinical quality measures (eCQMs) to assess the quality of colorectal and lung cancer diagnosis. Each measure used data from the electronic health record (EHR) to identify abnormal test results, evidence of appropriate follow-up, and exclusions that signified unnecessary follow-up. The authors describe the measure testing results and outline the challenges in working with unstructured EHR data.
Fisher L, Hopcroft LEM, Rodgers S, et al. BMJ Medicine. 2023;2:e000392.
Pharmacists play a critical role in medication safety. This article evaluated the impact of a pharmacist-led information technology intervention (PINCER) among a retrospective cohort of 56.8 million National Health Service (NHS) patients across 6,367 general practices between September 2019 and September 2021. Findings indicate that potentially dangerous prescribing (i.e., prescribing medications to patients without associated blood test monitoring, co-prescribing medications with adverse indications, prescribing medications to patients with certain comorbidities) was largely unaffected by the COVID-19 pandemic.
Staal J, Zegers R, Caljouw-Vos J, et al. Diagnosis (Berl). 2022;10:121-129.
Checklists are increasingly used to support clinical and diagnostic reasoning processes. This study examined the impact of a checklist on electrocardiogram interpretation in 42 first-year general practice residents. Findings indicate that the checklist reduced the time to diagnosis but did not affect accuracy or confidence.
Coghlan A, Turner S, Coverdale S. Intern Med J. 2023;53:550-558.
Use of abbreviations in electronic health records increases risk of misunderstandings, particularly between providers of different specialties. In this study, junior doctors and general practitioners were asked about their understanding of common, uncommon, and rare abbreviations used in hospital discharge notes. No abbreviation was interpreted in the same way by all respondents, and nearly all respondents left at least one abbreviation blank or responded that they didn't know.

Lai B, Horn J, Wilkinson J, et al. Fam Pract Manag. 2023;30(2):13-17.

Morbidity and mortality (M&M) conferences are an established mechanism used to facilitate discussion of errors to generate learning. This peer-reviewed article discusses how one organization implemented an M&M program. The authors share steps taken to support success which include case selection, nonjudgmental culture, and subject matter expert involvement.
Garzón González G, Alonso Safont T, Zamarrón Fraile E, et al. Int J Qual Health Care. 2023;35:mzad019.
Research into the nature, type, and contributing factors of adverse events (AE) in primary care is required to develop successful safety interventions. This study used medical record review to determine the prevalence, preventability, severity, type, and contributory factors of AE in primary care in Madrid, Spain. The prevalence of AEs was 5%, with the majority determined to be preventable. Most resulted in mild harm, and most contributory factors were patient-related (e.g., self-administered medications).