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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 642 Results
Loo VC, Kim S, Johnson LM, et al. J Patient Saf. 2023;19:460-464.
Ensuring the safety of clinical trial participants is paramount to successful, meaningful clinical research. In this study, researchers examined 585 clinical trial documents and found that 17% included potential patient safety interventions (e.g., resolving medication dosing discrepancies). The authors suggest that clinical specialists’ review of study protocol documents could enhance patient safety during clinical trial conduct.

World Health Organization.

The sharing of best practices is a key component of enabling successful strategy implementation in support of patient safety plans and goals. This website will capture, organize, and share experiences worldwide to support knowledge sharing and community building to reduce World Patient Safety Day targeted challenges.
Kane J, Munn L, Kane SF, et al. J Gen Intern Med. 2023;Epub Sept 5.
Clinicians and staff are encouraged to speak up about safety concerns as a part of patient safety culture. This review had two aims: to review the literature on speaking up for patient safety, and to develop a single definition of "speaking up" in healthcare. 294 articles were identified with 51 directly focused on speaking up and the remaining on other aspects such as communication. 11 distinct definitions were identified from which the authors developed a single definition: a healthcare professional identifying a concern that might impact patient safety and using his or her voice to raise the concern to someone with the power to address it.

Rockville, MD: Agency for Healthcare Research and Quality: September 2023.

Patient safety progress is dynamic, consistently producing evidence for application to generate improvements. This report is the fourth in a series funded by the Agency for Healthcare Research and Quality to track a prioritized set of emerging and existing safety approaches to confirm their value and effectiveness. This report will be compiled as new conclusions are formulated. Each review will be posted to the collection as they are completed. The first three Making Healthcare Safer reports, published in 2001, 2013, and 2020, have each served as a consolidated evidence source for clinicians, health system leadership, researchers, and government agencies. Chapter protocols and the results of an examination of harms associated with video-based telehealth are now available. 
Rao A, Pang M, Kim J, et al. J Med Internet Res. 2023;25:e48659.
Interest in testing ChatGPT as a clinical tool is increasing. This study asked ChatGPT to provide a differential diagnosis, diagnostic testing, final diagnosis, and care management for 36 previously published clinical vignettes. ChatGPT had an overall accuracy of 72%, with the highest level of accuracy at the final diagnosis stage (77%).
Harada Y, Watari T, Nagano H, et al. Diagnosis. 2023;Epub Aug 10.
Atypical presentation of common conditions or typical presentation or rare conditions may result in delayed diagnosis and treatment. This article uses 560 case reports to classify contributing factors to diagnostic errors in rare conditions and/or atypical presentations of common conditions. The results indicate that for less common and more atypical conditions, failure or delay in considering the final diagnosis becomes an increasingly important contributor to diagnostic error.

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.

The Armstrong Institute Center for Diagnostic Excellence. Johns Hopkins University, Baltimore, MD, September 27, 9:00 AM-4:00 PM (eastern).

Advanced computer technologies and data analysis are an increasing focus in diagnostic safety efforts. The theme of this annual event is “Diagnostic Digital Health Research”. Ethical use of artificial intelligence, consumer diagnostic technology and digital diagnostics and amongst the topics to be covered.
Wells M, Henry B, Goldstein L. Prehosp Disaster Med. 2023;38:471-484.
Inaccurate estimations of patient weight can lead to medication errors in the prehospital period. This systematic review of 9 studies concluded that there is insufficient evidence to assess the accuracy of weight estimation approaches used in the EMS setting or by paramedics, underscoring the need for additional, robust research in this area.

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.
Perspective on Safety August 30, 2023

This piece discusses virtual nursing, an approach to care that incorporates an advanced practice nurse into hospital-based patient care through telehealth. Virtual nursing increases patient safety and may enable expert nurses to continue to meet patient needs in future staffing shortages.

This piece discusses virtual nursing, an approach to care that incorporates an advanced practice nurse into hospital-based patient care through telehealth. Virtual nursing increases patient safety and may enable expert nurses to continue to meet patient needs in future staffing shortages.

Kathleen Sanford

Editor’s note: Kathleen Sanford is the chief nursing officer and an executive vice president at CommonSpirit. Sue Schuelke is an assistant professor at the College of Nursing–Lincoln Division, University of Nebraska Medical Center. They have pioneered and tested a new model of nursing care that utilizes technology to add experienced expert nurses to care teams, called Virtual Nursing.

Rockville, MD: Agency for Research and Quality; July 27, 2023. Notice Number NOT-HS-23-018.

Diagnostic errors occur in all settings of care and are a primary challenge to safe health care. This announcement raises awareness of two upcoming funding opportunities for understanding and improving diagnostic safety in diverse ambulatory care environments. The funding will target the incidence and contributory factors of diagnostic error within the array of ambulatory care services and the development of strategies and interventions to improve diagnostic safety in ambulatory care.
Zińczuk A, Rorat M, Simon K, et al. Viruses. 2023;15:1430.
The COVID-19 pandemic exacerbated many existing patient safety challenges. This retrospective analysis of 477 fatal COVID-19 cases at one hospital in Poland found that one-third of patients experienced a healthcare-acquired infection during their hospitalization as well as other hospital-acquired complications, including thrombolytic and/or bleeding complications, acute kidney injury, and exacerbation of chronic heart disease. The analysis also found that many patients experienced delays in specialist treatment (33%) or lack of specialist treatment (17%) during their hospitalization.
Lyren A, Haines E, Fanta M, et al. BMJ Qual Saf. 2023;Epub Jul 17.
Previous research has found that racial and ethnic disparities can hinder the safe care of pediatric patients. In this cross-sectional study, researchers examined racial and ethnic disparities in central line-associated bloodstream infection (CLABSI) and unplanned extubation (UE) rates across 27 children’s hospitals in the United States. Compared to White patients, Black and African-American patients had higher UE rates and Hispanic, Native American, and Pacific Islander patients had higher CLABSI rates.

Rosen M, Dy SM, Stewart CM, et al. Making Healthcare Safer IV Series.  Rockville, MD: Agency for Healthcare Research and Quality; July 2023. AHRQ Publication no. 23-EHC019-1.

Reducing preventable harm in healthcare settings remains a national priority. This report summarizes the results of the prioritization process used to identify patient safety practices meriting inclusion in the fourth installment of the Making Healthcare Safer (MHS) series (previous installments were published in 2001, 2013, and 2020). The fifteen-member Technical Expert Panel identified 27 priority patient safety practices for examination in the forthcoming report, including several practices that have not been covered in previous MHS reports (e.g., family/caregiver engagement, preventing non-ventilator associated pneumonia, supply chain disruption, high reliability, post-event communication programs).
Centola D, Becker J, Zhang J, et al. Proc Natl Acad Sci U S A. 2023;120:e2108290120.
Collective intelligence posits that the judgment (in this case, diagnostic accuracy) of a group of individuals outperforms the judgment of a single individual. This study sought to determine if real-time information-sharing improved not only group diagnostic accuracy, but also diagnostic accuracy of the individuals within the group. Individual accuracy did improve, suggesting real-time information-sharing between physicians could improve diagnostic decision-making in practice, although additional research is required.

Agency for Healthcare Research and Quality, Rockville, MD. July 2023.

Engaging patients to capture their insights after diagnostic error is one of the top patient safety strategies. This pair of issue briefs describes how organizations can use patient experience to inform improvements in diagnosis. Volume 1: Why Patient Narratives Matter highlights how patient perspectives offer unique information about the impacts of diagnosis-related events on patient care trajectories through the healthcare system. Volume 2: Eliciting Patient Narratives emphasizes that rigorous methods are needed to elicit patient experiences. Both briefs identify areas in which more research is needed about patients’ diagnostic experience.
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.