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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 1369 Results

ISMP Medication Safety Alert! Acute care edition. February 23, 2023;28(4):1-4; March 9, 2023:28(5):1-4.

Drug diversion can reduce patient safety and should be addressed at a system level to reduce its occurrence and impact. Part I of this two-part series examines ways in which drug diversion can affect care teams, and outlines what to watch for to flag its occurrence at the clinician, record keeping, and medication inventory levels. Part II shares tactics to minimize controlled substance diversion, and track, document and take action when it does occur.
Curated Libraries
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.
Thomas AD, Pandit C, Krevat SA. J Patient Saf. 2023;19:67-70.
Previous research has identified disparities in adverse events and patient safety risks for Black patients compared to White patients. In this study, researchers used a large healthcare system’s malpractice database to examine racial differences in malpractice lawsuits. Although there were no significant race differences in lawsuits, findings suggest that employees are more likely to identify potential malpractice events for White patients compared to Black patients.
Hyman DA, Lerner J, Magid DJ, et al. JAMA Health Forum. 2023;4:e225436.
Prior research has shown that physicians with more than three paid medical malpractice claims are at increased risk of another claim in the next two years. This study assessed the risk of additional claims after just one paid malpractice claim, whether public disclosure of claims increased the risk, and whether the risk changes over time. The authors also compare actual claims rates to simulated rates if malpractice claims were “random” events unrelated to prior claims.
Institute for Safe Medication Practices. April 13-14, 2023.
This virtual workshop will explore tactics to ensure medication safety, including strategic planning, risk assessment, and Just Culture principles.
Society to Improve Diagnosis in Medicine. Cleveland, Ohio, October 8-11, 2023.
Diagnostic error reduction continues to gain momentum in the research and frontline patient safety communities. This in-person conference will focus on the theme, "The Future of Diagnosis: Achieving Excellence and Equity." The deadline for submitting workshop concepts for program consideration is March 10, 2023.
Vacheron C-H, Acker A, Autran M, et al. J Patient Saf. 2023;19:e13-e17.
Wrong-site, wrong-procedure, and wrong-patient errors (WSPEs) are serious adverse events. This retrospective analysis of medical liability claims data examined the incidence of WSPEs in France between 2007 and 2017. During this ten-year period, WSPEs accounted for 0.4% of all claims. Procedures on the wrong organ were most common (44%), followed by wrong side (39%), wrong person (13%) and wrong procedure (4%). The researchers found that the average number of WSPEs decreased after implementation of a surgical checklist.

Institute for Healthcare Improvement. Gaylord National Resort and Convention Center, National Harbor, MD, May 22–24, 2023.

This annual conference will host pre-session workshops, panels, and presentations covering a variety of patient safety topics that align with the national agenda for patient safety improvement such as learning systems and leadership. Sessions will take place in-person.
Kramer DB, Yeh RW. JAMA. 2023;329:136-143.
The Food and Drug Administration (FDA) plays an important role in ensuring the safety of medical devices. In this cross-sectional study, researchers identified a high risk of future Class 1 FDA recall (the most serious recall designation, indicating serious risks to patient safety) among previously authorized devices (predicates) with prior Class 1 recalls.

Institute for Healthcare Improvement. Mar 14 - May 16, 2023.

Root cause analysis (RCA) is a widely recognized retrospective strategy for learning from failure that is challenging to implement. This series of webinars will feature an innovative approach to RCA that expands on the concept to facilitate its use in incident investigations. Instructors for the series will include Dr. Terry Fairbanks and Dr. Tejal K. Gandhi.
Apathy NC, Howe JL, Krevat SA, et al. JAMA Health Forum. 2022;3:e223872.
Electronic Health Record (EHR) systems are required to meet meaningful use and certification standards to receive incentive payments from the US Department of Health and Human Services (HHS). This study identified six settlements reached between EHR vendors and the Department of Justice for misconduct related to certification of meaningful use. Certification of EHR systems that don’t meet HHS meaningful use requirements may have implications for patient safety.
Rowland SP, Fitzgerald JE, Lungren M, et al. NPJ Digit Med. 2022;5:157.
The rapid expansion of digital health technologies, particularly in response to the COVID-19 pandemic, can increase patient safety risks. This article summarizes malpractice liability risks associated with digital health technologies, including electronic health record (EHR) systems, telehealth, and artificial intelligence for clinical decision support.
Carmack A, Valleru J, Randall KH, et al. Jt Comm J Qual Patient Saf. 2023;49:3-13.
Retained surgical items (RSI) are a never event, a serious and preventable event. After experiencing a high rate of RSIs, this United States health system implemented a bundle to reduce RSI, improve near-miss reporting, and increase process reliability in operating rooms. The bundle consisted of five elements: surgical stop, surgical debrief, visual counters, imaging, and reporting.
WebM&M Case November 16, 2022

A 58-year-old man underwent a complex surgery to replace his aortic valve. The surgery required prolonged cardiopulmonary bypass time and cross-clamp time and there was a short delay in redosing the cardioplegic solution and the patient developed “stone heart” due to suspected ischemic injury and was unable to come off bypass. The patient was placed on extracorporeal membrane oxygenation (ECMO) and transported to the ICU to allow family members to see the patient before stopping life support.

Andraska EA, Phillips AR, Asaadi S, et al. J Surg Educ. 2023;80:102-109.
Patients and clinicians may hold implicit gender biases and rate women clinicians more negatively. In this study, adverse event reports written about residents were reviewed to determine if resident gender was associated with different types and frequency of incident reports. The most comment complaint about men physicians involved a medical error, while the most common complaint type about women included a communication-related event. Additionally, women were more frequently identified by name only, without a title such as “doctor”.
Costin I-C, Marcu LG. Crit Rev Oncol Hematol. 2022;178:103798.
Radiotherapy errors can be significant and sometimes fatal. This systematic review describes errors in patient set up based on verification systems, the immobilization devices used, and the patient’s positioning during breast cancer treatment. The advantages and drawbacks of the most common position verification systems, error types associated with immobilization systems, and the influence of treatment position are reviewed.
Krvavac S, Jansson B, Bukholm IRK, et al. Int J Environ Res Public Health. 2022;19:10686.
Inpatient suicide is sentinel event. This study examined treatment patterns among patients undergoing inpatient or outpatient psychiatric treatment who died by suicide. The research team found that patients who were primarily treated with medications were less likely to be sufficiently monitored, whereas patients who received both psychotherapy and medication were more likely to receive inadequate treatment.
Reader TW. J Risk Res. 2022;25:807-824.
Feedback from patients and other stakeholders can illuminate serious patient safety concerns. This qualitative study analyzed stakeholder feedback about patient safety risks as well as how organizations responded to stakeholder communication and discusses ways in which organizational risk management teams can leverage stakeholder feedback. Findings suggest that stakeholder communications have typically focused on safety issues such as medication errors, but that poor safety culture meant that concerns were often not acted upon.