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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 569 Results
Woodier N, Burnett C, Moppett I. J Patient Saf. 2022;19:42-47.
Reporting and learning from adverse events is a core patient safety activity. Findings from this scoping review indicate limited evidence demonstrating that reporting and learning from near-miss events improves patient safety. The authors suggest that future research further explore this relationship and establish the effectiveness of system-level actions to avoid near misses.
Dillner P, Eggenschwiler LC, Rutjes AWS, et al. BMJ Qual Saf. 2022;Epub Dec 26.
Retrospective error detection methods, such as trigger tools, are widely used to uncover the incidence and characteristics of adverse events (AE) in hospitalized children. This review sought AEs identified by three trigger tools: Global Trigger Tool (GTT), the Trigger Tool (TT) or the Harvard Medical Practice Study (HMPS) method. Results from the trigger tools were widely variable, similar to an earlier review in adult acute care, and suggest the need for strengthening reporting standards.
Kelly D, Koay A, Mineva G, et al. Public Health. 2022;214:50-60.
Natural disasters and other public health emergencies (PHE), such as the COVID-19 pandemic, can dramatically change the delivery of healthcare. This scoping review identified considerable research examining the relationship between public health emergencies and disruptions to personal medication practices (e.g., self-altering medication regimens, access barriers, changing prescribing providers) and subsequent medication-related harm.
Agarwal AK, Sagan C, Gonzales R, et al. J Am Coll Emerg Physicians Open. 2022;3:e12870.
Black patients who report experiencing racism in healthcare report poorer quality of care. In this text-message based study, Black and White patients discharged from the emergency department (ED) were asked about their overall quality of care and whether they perceived an impact of their race on their care. While Black patients reported high overall quality of care, 10% believed their race negatively impacted their care. The authors highlight the importance of asking about the impact of race on care to identify and reduce potential disparities.

REPAIR Project Steering Committee. Acad Med. 2022;97(12):1753-1759. 

The REPAIR (REParations and Anti-Institutional Racism) Project at the University of California, San Francisco, aims to repair racial injustices in medical care and research. This article discusses the development of the initiative, the three annual themes (reparations, abolition, decolonization), and outcomes from its first year.
Skead C, Thompson LH, Kuk H, et al. Crit Care Res Pract. 2022;2022:4815734.
After-hours and weekend admissions to the hospital and intensive care units (ICU) have been linked to poor outcomes. This retrospective analysis compared outcomes among adult patients with daytime versus nighttime ICU admissions at one large Canadian medical center in between 2011 and 2015. Researchers found that overall mortality, but not ICU mortality, was higher among daytime admissions.

Newman-Toker DE, Peterson SM, Badihian S, et al. Rockville, MD: Agency for Healthcare Research and Quality; December 2022. AHRQ Publication No. 22(23)-EHC043.

Although diagnostic accuracy in the emergency department (ED) is high, diagnostic errors still occur. This evidence review estimated that 1 in 18 ED patients receive an incorrect diagnosis, which translates to 7.4 million patients misdiagnosed every year (or 5.7% of all ED visits annually). Five conditions were found to be most vulnerable to misdiagnosis: stroke, heart attack, aortic aneurysm/ dissection, spinal cord injury and blood clots. The evidence review identified variation in diagnostic error rates across demographic groups; female sex and non-White race were often associated with increased risk for diagnostic errors. Serious misdiagnosis-related harms were often associated with clinician bedside judgement and other cognitive failures. 
Hailu EM, Maddali SR, Snowden JM, et al. Health Place. 2022;78:102923.
Racial and ethnic health disparities are receiving increased attention, and yet structural racism continues to negatively impact communities of color. This review identified only six papers studying the impact of structural racism on severe maternal morbidity (SMM). Despite heterogeneity in measures and outcomes, the studies all demonstrated a link between structural racism and SMM; additional research is required.
Varady NH, Worsham CM, Chen AF, et al. Proc Natl Acad Sci USA. 2022;119:e2210226119.
Safe prescribing dictates that prescriptions should only be written for the patients who are intended to use the prescribed medications. Using claims data, this analysis identified a high rate of opioid prescriptions written for and filled by the spouses of patients undergoing outpatient surgery (who may be unable to fill prescriptions themselves after surgery). Findings suggest intentional, clinically inappropriate prescribing of opioids.
Oura P, Sajantila A. J Public Health Res. 2022;11:227990362211399.
Although patient safety is a national priority, preventable harm among patients remains high. After analyzing national death certificate data from 1999 through 2019, researchers in this study found that medical adverse events were listed as the underlying cause of death in 0.24% of deaths. From 2014 to 2019, researchers identified a nearly 16% annual increase in deaths attributed to adverse events, primarily driven by procedure-related adverse events and possibly related to the implementation of ICD-10 in 2015.
Henry Basil J, Premakumar CM, Mhd Ali A, et al. Drug Saf. 2022;45:1457-1476.
Medication administration errors (MAEs) are thought to be common in neonatal intensive care units (NICUs). This systematic review estimated that the pooled prevalence of MAEs among patients in NICU settings ranged from 59% to 65%. The review highlights both active failures (e.g., similar drug packaging or names) and latent failures (e.g., noisy environments, inaccurate verbal or written orders) contributing to MAEs.
Marsh KM, Turrentine FE, Schenk WG, et al. Ann Surg. 2022;276:e347-e352.
The perioperative period represents a vulnerable time for patients. This retrospective review of patients undergoing surgery at one hospital over a one-year period concluded that medical errors (including, but not limited to, technical errors, diagnostic errors, system errors, and errors of omission) were strongly associated with postoperative morbidity.
Wallerstedt SM, Svensson SA, Lönnbro J, et al. JAMA Netw Open. 2022;5:e2236757.
Criteria, such as the Screening Tool of Older Persons' Prescriptions (STOPP)/Screening Tool to Alert to Right Treatment (START) criteria, are tools used by clinicians to identify potentially inappropriate prescribing (PIM) and potential prescribing omissions (PPOs) among older adult patients. In this study, researchers evaluated three PIM/PPO criteria sets and found that all three performed poorly as diagnostic tools to identify inadequate drug treatment in older patients compared to counting the number of drugs on the patient’s medication list.
Averill P, Vincent CA, Reen G, et al. Health Expect. 2022;Epub Nov 12.
Patient safety research on inpatient psychiatric care is expanding, but less is known about outpatient mental health patient safety. This review of safety in community-based mental health services revealed several challenges, including defining preventable safety events. Additionally, safety research has focused on harm caused by the patient instead of harm caused by mental health services, such as delays in access or diagnosis.
Ostrovsky D, Novack V, Smulowitz PB, et al. JAMA Network Open. 2022;5:e2241461.
Previous research has found that fear of malpractice can influence medical decision-making. This survey of emergency department attending physicians and advanced practice clinicians in Massachusetts found that fear of harming patients played a larger role in medical decision-making than fear of legal action.

Eldeib D. ProPublica. November 13, 2022.

Pregnancy is recognized as a high-risk condition for both mother and infant. This news story examines the potential for stillbirth and its preventability. Lack of respect for the concerns of mothers, inadequate attention to research, and poor patient education are discussed as contributors to stillbirth.
Angel M, Bechard L, Pua YH, et al. Age Ageing. 2022;51:afac225.
People taking medications at home may have difficulty opening packaging which can result in improper, dangerous storage practices. This review includes 12 studies where participants were observed opening a variety of medication packages (e.g., blister packs, child-resistant containers). While all studies reported participant difficulty, no consistent contributory factors were identified, and the methodological quality of all studies was typically low. Additional research is required to encourage improvement in medication packaging.

Schneider E, Koretz BK, eds. Clin Geriatr Med. 2022;38(4):621-732.

Polypharmacy is a known contributor to medication complexity and error. This special issue examines the impact unnecessary medications have in a variety of care environments, such as nursing homes and emergency departments, and clinical areas, such as oncology and behavioral health.

National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2022. ISBN 9780309696333. 

The care of older adult patients can be complicated due to comorbidities, bias and polypharmacy. This publication reports on a session that examined diagnostic challenges unique to the older adult population. The existing evidence base and strategies for the future are reviewed.