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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 49 Results
WebM&M Case October 27, 2022

A 47-year-old man underwent a navigational bronchoscopy with transbronchial biospy under general anesthesia without complications. The patient was transferred to the post-acute care unit (PACU) for observation and a routine post-procedure chest x-ray (CXR). After the CXR was taken, the attending physician spoke to the patient and discussed his impressions, although he had not yet seen the CXR. He left the PACU without communicating with the bedside nurse, who was caring for other patients. The patient informed the nurse that the attending physician had no concerns.

Fawzy A, Wu TD, Wang K, et al. JAMA Intern Med. 2022;182:730-738.
Black and brown patients have experienced disproportionately poorer outcomes from COVID-19 infection as compared with white patients. This study found that patients who identified as Asian, Black, or Hispanic may not have received timely diagnosis or treatment due to inaccurately measured pulse oximetry (SpO2). These inaccuracies and discrepancies should be considered in COVID outcome research as well as other respiratory illnesses that rely on SpO2 measurement for treatment.
Wang Y, Eldridge N, Metersky ML, et al. JAMA Netw Open. 2022;5:e2214586.
Hospital readmission rates are an important indicator of patient safety. This cross-sectional study examined whether patients admitted to hospitals with high readmission rates also had higher risks of in-hospital adverse events. Based on a sample of over 46,000 Medicare patients with pneumonia discharged between July 2010 and December 2019 and linked to Medicare adverse event data, researchers found that patients admitted to hospitals with high all-cause readmission rates were more likely to experience an adverse event during their admission.
Trenton, NJ: New Jersey Department of Health and Senior Services.
Detailing results of an error reporting initiative in New Jersey, these reports explain how consumers can use this information and provides tips for safety when obtaining health care. A section highlights findings related to patient safety indicators.
Papaioannou AI, Bartziokas K, Hillas G, et al. Postgrad Med. 2021;133:524-529.
Incorrect use of medical devices can lead to unfavorable outcomes. In this study of 663 patients with asthma and/or chronic obstructive pulmonary disease (COPD), 41% demonstrated incorrect use of their inhaler. Incorrect use was more common among older patients and associated with more acute exacerbations.
WebM&M Case August 25, 2021

A 31-year-old woman presented to the ED with worsening shortness of breath and was unexpectedly found to have a moderate-sized left pneumothorax, which was treated via a thoracostomy tube. After additional work-up and computed tomography (CT) imaging, she was told that she had some blebs and mild emphysema, but was discharged without any specific follow-up instructions except to see her primary care physician.

Singh D, Fahim G, Ghin HL, et al. J Pharm Pract. 2021;34:354-359.
Pharmacist-led medication reconciliation has been found to reduce medication discrepancies for some patients. This retrospective study examined the impact of pharmacist-conducted medication reconciliation among patients with chronic obstructive pulmonary disease (COPD). While pharmacist-conducted medication reconciliation identified medication dosing and frequency errors, it did not reduce 30-day readmission rates for patients with COPD.

Jørgensen IF, Brunak S. NPJ Digital Med. 2021;4(1):12.

Overdiagnosis is a growing area of concern within patient safety. The authors present a generalizable approach for identifying patients at risk of being mis- or overdiagnosed. Using chronic obstructive pulmonary disease (COPD) patients as an example, the authors outline how to create significant, temporal disease trajectories, and compare similarities between these disease trajectories and individual patient disease histories to identify the cases that may signal overdiagnosis.
Sjoding MW, Dickson RP, Iwashyna TJ, et al. N Engl J Med. 2020;383:2477-2478.
Pulse oximetry is used to triage patients, initiate or adjust oxygen administration, and, more recently, as a way to remotely monitor COVID-19 patients at home. However, a study in the Johns Hopkins Health System showed that Asian, Black, or Hispanic patients are more likely to experience inaccurate readings, potentially resulting in missed or delayed diagnosis of respiratory diseases. This study used paired oxygen saturation by pulse oximetry and arterial oxygen saturation in arterial blood gas in Black and white patients before and during the COVID-19 pandemic. Consistent with the Johns Hopkins study, Black patients had three times the frequency of occult hypoxia than white patients.
Emani S, Sequist TD, Lacson R, et al. Jt Comm J Qual Patient Saf. 2019;45:552-557.
Health care systems struggle to ensure patients with precancerous colon and lung lesions receive appropriate follow-up. This academic center hired navigators who effectively increased the proportion of patients who completed recommended diagnostic testing for colon polyps and lung nodules. A WebM&M commentary described how patients with lung nodules are at risk for both overtreatment and undertreatment.
Palmer J. Patient Saf Qual Healthc. May/June 2019.
Organizations must learn from adverse events to prevent similar incidents. Reporting on lessons to be learned from the cascade of failures connected with the preventable death of a patient during an acute asthma attack at the door of a hospital emergency department, this magazine article outlines the importance of effective signage, appropriate security staff placement, and acceptance of the responsibility for failure.
WebM&M Case June 1, 2019
A proceduralist went to perform ultrasound and thoracentesis on an elderly man admitted to the medicine service with bilateral pleural effusions. Unfortunately, he scanned the wrong patient (the patient had the same last name and was in the room next door). When the patient care assistant notified the physician of the error, he proceeded to scan the correct patient. He later nominated the assistant for a Stand Up for Safety Award.

Cortegiani A, Gregoretti C, Neto AS, et al; LAS VEGAS Investigators, PROVE Network, Clinical Trial Network of the European Society of Anaesthesiology. Br J Anaesth. 2019;122:361-369.

This study found that patients undergoing surgery at night were more likely to develop intraoperative adverse events, even after adjustment for patient and procedural characteristics. The observed increase in postoperative pulmonary complications was explained by the type of surgery and underlying patient characteristics. This study adds to the body of evidence on risks associated with care outside of usual working hours.
WebM&M Case April 1, 2019
A woman who required oxygen at home via nasal cannula and used a continuous positive airway pressure (CPAP) machine at night was admitted for an exacerbation of chronic obstructive pulmonary disease without any signs of infection. During her hospital stay, she continued to require 5 liters of oxygen by nasal cannula. Although the patient had received smoking cessation education and no longer smoked regular cigarettes, she did continue to vape with an electronic cigarette (e-cigarette).
WebM&M Case March 1, 2019
Following an elective carotid endarterectomy, an elderly woman was extubated in the operating room (OR) and brought to the recovery area. She soon developed respiratory distress necessitating urgent reintubation, which required multiple attempts. She was found to have an expanding neck hematoma, which was drained safely in the OR. Later that day after a half hour weaning trial, the respiratory therapist extubated the patient without checking for a cuff leak. Within 15 minutes, she developed acute shortness of breath and stridor, which rapidly progressed to hypoxemic respiratory failure.
Aaron SD, Vandemheen KL, FitzGerald M, et al. JAMA. 2017;317:269-279.
Misdiagnosis can contribute to overuse of unnecessary medication and treatments as well as a delay in appropriate treatment, placing patients at increased risk of harm. This prospective cohort study suggests that asthma may be frequently misdiagnosed in the community setting as a result of inadequate testing for airflow limitations. In 2% of the cases analyzed, a serious underlying cardiorespiratory condition was misdiagnosed as asthma.
Nguyen MC, Moffatt-Bruce SD, Strosberg DS, et al. Surgery. 2016;160:858-868.
The AHRQ Patient Safety Indicators (PSIs) rely on hospital administrative data to screen for patient safety problems. This study used independent physician chart review to assess the reliability of PSI 11 (postoperative respiratory failure) in identifying clinically significant patient safety events and found a positive predictive value of 38.3%. The authors argue that PSI 11 should not be used as a measure for hospital performance.
Patients and clinicians can make medication administration mistakes when new drug delivery mechanisms are introduced. This newsletter article reviews common errors associated with the use of inhalers and offers recommendations for patients, nurses, respiratory therapists, pharmacists, and health care organizations to educate patients on the use of these medications.