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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 740 Results
Zhong A, Amat MJ, Anderson TS, et al. JAMA Netw Open. 2023;6:e2343417.
Increased use of telehealth presents both benefits and potential threats to patient safety. In this study of 4,133 patients, researchers found that orders for colonoscopies or cardiac stress tests and dermatology referrals placed during telehealth visits were less likely to be completed within the designated timeframe compared to those ordered during in-person visits (43% vs. 58%). Not completing test or referrals within the recommended timeframe can increase the risk of delayed diagnoses and patient harm.
Metz VE, Ray GT, Palzes V, et al. J Gen Intern Med. 2023;Epub Nov 6.
In response to the increasing opioid crisis, many medical associations, policy makers, and insurers have argued for dose reductions. However, when doses are reduced too quickly, patients may experience short- and long-term adverse events. Consistent with other studies, dose reductions higher than 30% were associated with higher odds of emergency department visits, opioid overdose, and all-cause mortality in the month following dose reduction.
Lucas P, Jesus É, Almeida S, et al. BMC Nurs. 2023;22:413.
A poor work environment can have a negative impact on quality and safety of patient care. This study of primary care nurses in Portugal shows that better work practice environments are associated with higher quality of care, patient safety, and safety culture. Nursing foundations for quality of care and collegial nurse-physician relations were the highest rated survey dimensions.
Cam H, Wennlöf B, Gillespie U, et al. BMC Health Serv Res. 2023;23:1211.
When patients are discharged from the hospital, they (and their informal caregivers) are given copious amounts of information that must also be communicated to their primary care provider. This qualitative study of primary care and hospital physicians, nurses, and pharmacists highlights several barriers to complete and effective communication between levels of care, particularly regarding geriatric medication safety. Barriers include the large number of complex patients and incongruent expectations of responsibility of primary and hospital providers. Support systems, such as electronic health records, can both enable and hinder communication.
Olazo K, Gallagher TH, Sarkar U. J Patient Saf. 2023;19:547-552.
Marginalized patients are more likely to experience adverse events and it is important to encourage effective disclosure to reinforce and reestablish trust between patients and providers. This qualitative study involving clinicians and patient safety professionals explored challenges responding to and disclosing errors involving historically marginalized patients. Participants identified multilevel challenges, including fragmentation of care and patient mistrust as well a desire for disclosure training and culturally appropriate disclosure toolkits to support effective error disclosure.
Liu Y, Jun H, Becker A, et al. J Prev Alz Dis. 2023;Epub Oct 24.
Persons with dementia are at increased risk for adverse events compared to those without dementia, highlighting the importance of a timely diagnosis. In this study, researchers estimate approximately 20% of primary care patients aged 65 and older are expected to have a diagnosis of mild cognitive impairment or dementia; however, only 8% have received such a diagnosis. Missed diagnosis prevents patients from receiving appropriate care, including newly FDA-approved medications to slow cognitive decline.
Garzón González G, Alonso Safont T, Conejos Míquel D, et al. J Patient Saf. 2023;19:508-516.
Retrospective chart review is the standard for estimating prevalence of adverse events manual review of the electronic health record (EHR) is resource intensive. This study describes the construction and validation of electronic trigger set, TriggerPrim, to rapidly identify charts with potential adverse events in primary care. The resulting set has five triggers: ≥3 appointments in a week at the PC center, hospital admission, hospital emergency department visit, prescription of major opioids, and chronic benzodiazepine treatment in patients 75 years or older. Use of TriggerPrim reduced time in the EHR by half.
Huynh J, Alim SA, Chan DC, et al. Ann Intern Med. 2023;176:1448-1455.
Access to primary care is becoming more challenging, in part due to physicians leaving the field. Twenty-nine states have expanded nurse practitioner (NP) autonomy to increase access. This study compares potentially inappropriate prescribing practices between NPs and primary care physicians (PCP). In the study population, adults aged 65 and older, NPs and PCPs had nearly identical rates of potentially inappropriate prescribing. The authors encourage focusing on improving prescribing practices among all prescribers instead of working to limit prescribing to physicians.
Kavanagh KT, Cormier LE. Medicine (Baltimore). 2023;102:e35095.
Primary care plays an important role in identifying, avoiding and mitigating patient safety issues. This report highlights several patient safety priorities and how small (<10 providers) primary care practices can promote safe practice and outcomes for their patients.
Dorimain M-V, Plouffe-Malette M, Paquette M, et al. BMJ Open Qual. 2023;12:e002291.
Laboratory tests are an integral part of diagnosing illness and injury, but system issues can result in the delayed communication of results to patients. This article describes use of the AHRQ toolkit Improving Your Office Testing Process to implement new testing and communication procedures. As an academic family practice clinic, an important first step was allowing residents to order tests and receive results in their own name instead of through an attending physician, which can cause delays in communication to patients. Providers and patients were satisfied with the new process.
Young RA, Gurses AP, Fulda KG, et al. BMJ Open Qual. 2023;12:e002350.
Improving medication safety in ambulatory care settings is a patient safety priority. This qualitative study with primary care teams across four sites in the southwestern United States explored approaches to improving medication safety. Respondents emphasized the importance of customization and individualization (e.g., simplifying medication regimens for certain patients) and described how the principles of high reliability can help teams anticipate and respond to medication safety risks.
Kapoor A, Patel P, Mbusa D, et al. J Gen Intern Med. 2023;Epub Sep 27.
Pharmacists are frequently involved in medication reviews for hospitalized patients prescribed direct oral anti-coagulants (DOAC). This randomized controlled study explored pharmacist involvement with patients prescribed DOAC in ambulatory care. The intervention included up to three phone calls, electronic health record communication with the prescriber, and recommendations for lab work. After 90 days, there were no differences in clinically important medication errors between groups.
van Sassen CGM, van den Berg PJ, Mamede S, et al. Adv Health Sci Educ Theory Pract. 2023;28:893-910.
Improving clinical reasoning is an important component of medical education. Using a medical malpractice claims database, researchers in this study reviewed 50 conditions identified 15 priority conditions that can be used to improve clinical reasoning education for general practitioners. The conditions represent common (e.g., eye infection), complex common (e.g., renal insufficiency, cardiovascular disease, cancer), and complex rare conditions (e.g., ectopic pregnancy) and often demonstrate atypical presentations or complex contextual factors important for diagnostic reasoning.
Longo BA, Schmaltz SP, Williams SC, et al. Jt Comm J Qual Patient Saf. 2023;49:511-520.
Supporting and improving clinician well-being has long been a safety focus and received renewed focus during the COVID-19 pandemic. This study sought to understand efforts undertaken to support clinicians’ well-being in Joint Commission-accredited hospitals and Federally Qualified Health Centers (FQHC). Only half of responding hospitals and FQHCs reported implementing at least one action towards improving clinician well-being (e.g., establishing a wellness committee) and few had implemented a comprehensive approach.
Harrison J. Br Paramed J. 2023;8:18-28.
Patients with dark skin tones are not well represented in health education, particularly dermatology, which can result in delayed diagnosis. In this scoping review, thirteen articles were identified assessing the confidence of students and healthcare providers in assessing patients with dark skin tones.  Overall, confidence was low but tailored training somewhat improved confidence. The author asserts more research and education is needed outside dermatology, for example, when assessments use terms such as pale, redness, or blue.
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;219:325-331.
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.