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 713 Results

Changes in medication safety indicators in England throughout the covid-19 pandemic using OpenSAFELY: population based, retrospective cohort study of 57 million patients using federated analytics.

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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.

Impact of diagnostic checklists on the interpretation of normal and abnormal electrocardiograms.

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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.

Danger in discharge summaries: abbreviations create confusion for both author and recipient.

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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.

Using morbidity and mortality conferences to drive quality improvement and reduce errors.

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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.

Is primary care a patient-safe setting? Prevalence, severity, nature, and causes of adverse events: numerous and mostly avoidable.

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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).

Family conferences to facilitate deprescribing in older outpatients with frailty and with polypharmacy: the COFRAIL cluster randomized trial.

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Mortsiefer A, Löscher S, Pashutina Y, et al. JAMA Netw Open. 2023;6:e234723.

Polypharmacy among older adults can cause adverse health outcomes as well as adversely impact social outcomes, medication management, and healthcare utilization. The COFRAIL cluster randomized trial explored whether family conferences can promote deprescribing and reduce adverse outcomes related to polypharmacy in community-dwelling frail older adults. After 12 months of follow-up, the researchers did not find any significant difference in hospitalizations among patients randomized to family conferences or usual care. The number of potentially inappropriate prescriptions decreased among patients randomized to family conferences at 6-month follow-up, but this reduction was not sustained at the 12-month follow-up.

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Ude-Okeleke RC, Aslanpour Z, Dhillon S, et al. J Pharm Pract. 2023;36:357-369.

Older adults are particularly vulnerable to medication-related safety events. This systematic review including 21 studies on medication-related problems in in older adults identified several types of safety issues (e.g., potentially inappropriate prescribing, polypharmacy, adverse drug reactions) that lead to poor outcomes among older adults in nursing homes, inpatient care, and community settings. The authors found the classes of medication related problems are similar to studies from a decade ago, suggesting that more intensive monitoring is needed.

Burnout in Primary Care: Assessing and Addressing It in Your Practice.

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Gerteis J, Booker C, Brach C, et al. Rockville, MD: Agency for Healthcare Research and Quality; February 2023. AHRQ Publication No. 23-0025.

Burnout reduction in primary care is critical to patient safety. This resource is designed to help practices assess the causes of burnout in primary care and implement strategies to promote well-being. Suggested areas of focus include the reduction of documentation tasks, use of huddles and peer support.

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.

Potentiality of algorithms and artificial intelligence adoption to improve medication management in primary care: a systematic review.

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Damiani G, Altamura G, Zedda M, et al. BMJ Open. 2023;13:e065301.

Artificial intelligence (AI) is increasingly used to identify and prevent patient safety threats. This review focuses on AI used to reduce medication errors in the primary care setting. Most studies targeted the prescribing stage, and the main category of AI was computerized decision support system.

Patient safety tools for primary care.

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Domdera J. Fam Pract Manag. 2023;30(2):24-28.

A large segment of patients receives outpatient care. This commentary suggests that high-reliability concepts be applied in the primary care environment to reduce the potential for mistakes and patient harm. The author shares tools to address communication and care coordination problems.

Early diagnosis of cancer: systems approach to support clinicians in primary care.

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Black GB, Lyratzopoulos G, Vincent CA, et al. BMJ. 2023;380:e071225.

Primary care often initiates a diagnostic process that is vulnerable to miscommunication, uncertainty, and delay. This commentary examines how cancer diagnosis delay in primary care occurs. The authors suggest a systems approach targeting interconnected process elements including enhanced use of information technology to help with monitoring and care coordination to realize and sustain improvement.

"We're not taken seriously": describing the experiences of perceived discrimination in medical settings for Black women.

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Washington A, Randall J. J Racial Ethn Health Disparities. 2023;10:883-891.

Discrimination can contribute to health inequities and exacerbate disparities in cancer care. In this study, researchers used a survey tool and qualitative interviews to explore the experiences of perceived discrimination for Black women and how it impacts cervical cancer prevention. Study findings suggest that perceived high degrees of discrimination create mistrust between patients and providers and can impact health outcomes.

Which adverse events and which drugs are implicated in drug-related hospital admissions? A systematic review and meta-analysis.

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Haerdtlein A, Debold E, Rottenkolber M, et al. J Clin Med. 2023;12:1320.

Adverse drug events (ADE) can result in patient harm, hospital admissions, and, in severe cases, death. This systematic review and meta-analysis estimates the prevalence of preventable ADEs resulting in emergency department visits or hospitalization, and the types and prevalence of ADEs and implicated drugs.

Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists

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WebM&M Case March 15, 2023

A 71-year-old man presented to his physician with rectal bleeding and pain, which was attributed to radiation proctitis following therapy for adenocarcinoma of the prostate. He subsequently developed a potentially life-threatening complication of sepsis while awaiting follow up care for a spontaneous rectal perforation. The commentary addresses the importance of early identification and timely intervention in the event of treatment failure and the post-discharge follow-up programs to improve care coordination and communication during transitions of care.

Patient and health care professional perspectives on stigma in integrated behavioral health: barriers and recommendations.

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Phelan SM, Salinas M, Pankey T, et al. Ann Fam Med. 2023;21:s56-s60.

Stigma can prevent patients from seeking necessary mental health care. In this study, researchers conducted qualitative interviews with patients and health care providers to assess mental health stigma and barriers to use of integrated behavioral health (IBH) in primary care settings. Participants identified the importance of normalizing discussions about mental health care and patient-centered communication.

Minimize medication errors in urgent care clinics.

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Coffey SB. American Nurse Journal. Epub March 2, 2023.

Urgent care clinics offer services to a wide patient base that increase the complexities of medication prescribing and administration. Safety culture, process, and structural factors are discussed as avenues to increase safety in this unique ambulatory setting. The piece highlights the importance of education, rules, and storage procedures to ensure safe medication administration.

Curated Libraries

Value and Patient Safety

March 8, 2023

Value as an element of patient safety is emerging as an approach to prioritize and evaluate improvement actions. This library highlights resources that explore the business case for cost effective, efficient and impactful efforts to reduce medical errors.

Pharmacists reducing medication risk in medical outpatient clinics: a retrospective study of 18 clinics.

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Snoswell CL, De Guzman KR, Barras M. Intern Med J. 2023;53:95-103.

Community pharmacists play an important role in ensuring patient safety. This retrospective analysis of 18 outpatient pharmacy clinics evaluated pharmacist recommendations and impacts on medication-related safety. Researchers indicated that outpatient pharmacists were effective in resolving 82% of medication-related problems; 18% of these involved high-risk recommendations, such as medication interactions.

Association between opioid tapering and subsequent health care use, medication adherence, and chronic condition control.

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Magnan EM, Tancredi DJ, Xing G, et al. JAMA Netw Open. 2023;6:e2255101.

Rates of prescription opioid misuse and abuse led to recommendations for dose tapering for patients with chronic pain. However, concerns have been raised about the potential harms associated with rapidly decreasing doses or discontinuing opioids. Building on previous research, these researchers used a large claims database to explore the unintended negative consequences of tapering patients on stable, long-term opioid therapy. Findings indicate that opioid tapering was associated with fewer primary care visits, greater numbers of emergency department visits, and reduced adherence to antihypertensive and antidiabetic medications.

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