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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 29 Results

Agency for Healthcare Research and Quality.

Telemedicine efforts harbor both risk and reward to patients and providers. The AHRQ Safety Program for Telemedicine is a national effort to develop and implement a bundle of evidence-based interventions designed to improve telemedicine care in two settings—the cancer diagnostic process and antibiotic use. To test the bundle of interventions, the program will involve two cohorts of healthcare professionals who utilize telemedicine as a care delivery model. It is an 18-month program, beginning in June 2023, that seeks to improve the cancer diagnostic process for patients who receive some or all of their care through telemedicine. Recruitment webinars start in late January and run through early May 2023; the antibiotic use cohort will begin recruitment in December 2023. 
WebM&M Case January 7, 2022

A 52-year-old woman presented for a lumpectomy with lymphoscintigraphy and sentinel lymph node biopsy (SLNB) after being diagnosed with ductal carcinoma in situ (DICS). On the day of surgery, the patient was met in the pre-operative unit by several different providers (pre-operative nurse, resident physician, attending physician, and anethesiology team) to help prepare her for the procedure. In the OR, the surgical team performed two separate time-outs while the patient was being prepped, placed under general anesthesia, and draped.

Fan B, Pardo J, Yu-Moe CW, et al. Ann Surg Oncol. 2021;28:8109-8115.
While prior research has described malpractice cases related to breast cancer diagnosis and treatment, this study sought to identify errors specifically related to breast cancer surgical procedures. Plastic surgeons were the most commonly named provider type (64%), error in surgical treatment was the most common allegation (87%), and infection, cosmetic injury, emotional trauma, foreign body, and nosocomial infection were the top 5 injury descriptions.

Boodman SG. Washington Post. January 23, 2021.

Misdiagnosis can endure over a long period and delay a correct course of treatment. This news feature shares an example of depression misdiagnosis that masked the true problem of a neurological tumor manifesting in what was seen and treated as a psychological condition. 
Fearon NJ, Benfante N, Assel M, et al. Jt Comm J Qual Patient Saf. 2020;46:410-416.
Opioid prescriptions are associated with harm among postoperative patients. This quality improvement project reduced and standardize opioid prescriptions upon discharge for opioid-naive patients undergoing oncologic surgery and evaluated the impact on subsequent opioid use and reported pain. Pre-standardization, the median opioid prescription at discharge was 20 pills (up to 140 milligrams morphine equivalent, or MME); post-standardization, prescriptions were set to 7-10 pills (24-75 MME) depending on the type of oncologic surgery.
Weingart SN, Nelson J, Koethe B, et al. Cancer Med. 2020;9:4447-4459.
Using a cohort of adults diagnosed with breast, colorectal, lung or prostate cancer, this study examined the relationship between oncology-specific triggers and mortality. It found that patients with at least one trigger had a higher risk of death than patients without a trigger; this association was strongest for nonmetastatic prostate cancer and nonmetastatic colorectal cancer. Triggers most commonly associated with increased odds of mortality were bacteremia, blood transfusion, hypoxemia and nephrology consultation. These findings support the validity of cancer-specific trigger tool but additional research is needed to replicate these findings.
Kutikov A, Weinberg DS, Edelman MJ, et al. Ann Intern Med. 2020;172:756-758.
Oncology patients, as with other patients with chronic health care needs, face numerous challenges during the COVID-19 pandemic. The authors discuss the need to balance delays in cancer diagnosis or treatment against the harm of COVID-19 exposure, how to mitigate the risk for significant care disruptions associated with social distancing and managing the allocation of limited healthcare resources during this unprecedented pandemic.
Resio BJ, Hoag JR, Chiu AS, et al. JAMA Oncol. 2019;5:1359-1362.
As market pressures encourage health systems to consolidate, many community hospitals have established affiliations with top-ranked cancer care centers. Prior studies have suggested that care may be less safe at affiliates than at the cancer centers themselves. Researchers found that surgical outcomes were no different between cancer center–affiliated community hospitals when compared to nonaffiliated community hospitals after adjusting for hospital characteristics, patient characteristics, and secular trends.
Cullen A. Uitgeverij van Brug: The Hague, The Netherlands; 2019. ISBN: 9789065232236.
Patient stories offer important insights regarding the impact medical errors have on patients and their families. This book shares the author's experience with medical error and spotlights how lack of transparency in European health care can contribute to avoidable process failures that result in patient harm.
Hoag JR, Resio BJ, Monsalve AF, et al. JAMA Netw Open. 2019;2:e191912.
This cross-sectional study examined outcomes for Medicare patients undergoing complex cancer surgery at U.S. News and World Report top-ranked cancer hospitals and their affiliates. Investigators found that surgery performed at affiliated hospitals was associated with higher 90-day mortality and that the top-ranked hospital was safer than its affiliates in 84% of the networks in the study. The authors suggest that while affiliated hospitals may share branding with top-ranked cancer facilities, further study of such networks is necessary to inform care for cancer patients.
Varma S, Mehta A, Hutfless S, et al. Am J Obstet Gynecol. 2018;219:176.e1-176.e9.
Substantial debate continues as to whether the July effect—an increase in preventable adverse events in the summer when new resident physicians begin their training—represents a real phenomenon. Analyzing data across Maryland, investigators found no evidence for a seasonal increase in hysterectomy complication rates. A WebM&M commentary discussed possible interventions to reduce errors and care disruptions in July.
D'Agostino TA, Bialer PA, Walters CB, et al. AORN J. 2017;106:295-305.
Reluctance of health care team members to speak up about safety concerns can hinder patient safety. This pre–post study of a communication training program used findings from interdisciplinary focus groups to address barriers to speaking up. The training was highly rated and authors believe it has potential to improve team communication.
Sukumar S, Roghmann F, Trinh VQ, et al. BMJ Open. 2013;3.
This large study used AHRQ Patient Safety Indicators (PSIs) to assess the quality of surgical care in oncology across the United States. Although the frequency of potentially avoidable adverse events after major cancer surgery has increased over the past decade, overall mortality rates declined. The highest-volume hospitals in this study had lower PSI event rates and failure-to-rescue rates compared with lower-volume hospitals. This finding differs from prior studies that had found similar complication rates across hospitals and had suggested that the higher mortality seen at low-volume hospitals could be attributed solely to failures in rescuing patients once an event occurred. The authors propose that policy changes are required to prevent specific adverse events, such as postoperative sepsis and pressure ulcers. Dr. Patrick Romano discusses the utility of using PSIs to measure patient safety in an AHRQ WebM&M interview.
Mazor KM, Roblin DW, Greene SM, et al. J Clin Oncol. 2012;30:1784-1790.
Cancer patients may be particularly vulnerable to errors due to the complex, multidisciplinary nature of the care they require and the risks of the treatments they must undergo. This qualitative study of patients undergoing treatment for breast or colon cancer found that a significant proportion of patients perceived they had experienced a preventable adverse event, most commonly ascribed to poor communication or coordination of care. Most patients did not report their concerns to clinicians and did not feel that errors were fully disclosed. The accompanying editorial calls for clinicians to communicate more effectively with patients throughout their course of treatment and followup. Efforts are also underway to engage patients in safety by providing training in reporting errors and patient–provider communication.
Rutter CM, Johnson E, Miglioretti DL, et al. Cancer Causes & Control. 2011;23.
This study of more than 45,000 colonoscopies found that 4.7 serious adverse events occurred per 1000 screening colonoscopies. Advanced age and the need for polyp removal were associated with increased risk of adverse events.
Lamb BW, Sevdalis N, Vincent C, et al. Ann Surg Oncol. 2012;19:1759-65.
Multidisciplinary teamwork is essential in developing appropriate treatment plans for cancer patients, and teamwork failures have been implicated in several high profile errors. In this study, the investigators developed and implemented a quality improvement checklist to ensure thorough and patient-centered discussion and treatment planning.