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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 19416 Results
Beauvais B, Pradhan R, Ramamonjiarivelo Z, et al. Risk Manag Healthc Policy. 2024;17:1361-1372.
While staffing shortages in hospitals have existed for years, they were exacerbated by the COVID-19 pandemic. Many hospitals use agency, or temporary, staff to fill these gaps. This study used national data to explore the association of use of agency staff and hospital quality measures. The results demonstrate that increased use of agency staff is associated with decreased performance in most quality measures, including Hospital Compare star rating and Hospital Value-Based Purchasing (VBP) Total Performance Score (TPS). There was no association with hospital-wide all-cause readmission rate.
Blanchard MD, Herzog SM, Kämmer JE, et al. Med Decis Making. 2024;44:451-462.
Collective intelligence in diagnosis refers to the collaboration of multiple individuals to generate a more accurate diagnosis than could be made by a single clinician. This study examined the collective intelligence of diagnostic decision making in general practice and identified the conditions associated with the greatest increase in accuracy, as well as the benefit of a computerized decision support system (CDSS). Plurality substantially outperformed average individual accuracy and the most senior group member's accuracy.
Hirani R, Noruzi K, Khuram H, et al. Life (Basel). 2024;14:557.
Artificial intelligence (AI) applications in healthcare continue to grow. This article summarizes the history and evolution of AI in healthcare and describes current applications in healthcare, such as integration with telemedicine, and advancing personalized medicine. The authors also discuss how AI being used to advance patient engagement and communication (e.g., the use of chatbots for patient engagement) and medical education, as well as ethical considerations as healthcare continues to integrate AI into practice. 

Maternity and Newborn Safety Investigations Programme. Newcastle Upon Tyne, UK: Care Quality Commission; May 2024.

Safe maternal care is a challenge worldwide. This report analyzed 92 investigations that provided safety recommendations to improve midwifery-lead maternity care in the National Health Service. Areas of focus included workload, fetal heart monitoring during birthing, crisis preparedness, and telephone triage for pregnant persons.
Gleason KT, Tran A, Fawzy A, et al. Int J Nurs Stud. 2024;155:104770.
Continuous monitoring with pulse oximeters can alert nurses to changes in patient status, but, like most electronic monitors, they can malfunction, resulting in occult hypoxemia (i.e., failure of pulse oximeter to detect clinically meaningful hypoxemia). This study assessed the potential of using frequency of nursing documentation of provider notification to identify unrecognized hypoxemia. Patients with both evident and occult hypoxemia had increased nurse documentation in the four hours before the hypoxic event. Crucially, this finding was also true in Black patients, where pulse oximeters are less likely to detect hypoxemia.
Øyri SF, Wiig S, Tjomsland O. BMJ Open Qual. 2024;13:e002672.
Independent investigations and regulatory authorities examine individual and system weaknesses in health care settings to prevent harm. This qualitative study involving 15 Norwegian surgeons explored perceptions around external investigations after an adverse event and impacts on transparency, reporting, and learning. Participants highlighted concerns about criminalization and scapegoating, as well as conflicting understanding or culture between medical and regulatory perspectives. 
Bos K, van der Laan MJ, Groeneweg J, et al. BMJ Open Qual. 2024;13:e002592.
Strong recommendations coming out of sentinel event investigations are more likely to reduce recurrence of the event. This paper presents the recommendation improvement matrix (RIM), a method to grade the quality and strength of interventions. The RIM consists of two elements—whether the intervention occurs before or after the event and whether it eliminates or controls the hazard.
Daneshvar N, Pandita D, Erickson S, et al. Ann Intern Med. 2024.
The need to establish standards as artificial intelligence (AI) and machine learning are being incorporated into clinical care is paramount. This policy statement examines the use of these technologies by internists. Recommendations submitted by the American College of Physicians address transparency, decision making, privacy, equity, ethics, the patient-physician relationship, and well-being concerns. The policy concludes with a call for continued research to support the effective development and safe use of AI.
Jeffrey E, Dalby M, Walsh Á, et al. Explor Res Clin Soc Pharm. 2024;14:100451.
Automated dispensing cabinets (ADCs) are commonly used in hospitals to enhance medication safety. This systematic review including nine studies found that ADCs can decrease omitted or missed doses, but research is insufficient to determine the impact on delayed doses. 
Austria D, McConnell C, Pope C. J Patient Saf. 2024;20:272-278.
Inpatient nutritional errors can negatively impact a patient's recovery. This review identified fourteen studies investigating inpatient nutritional errors and subsequent patient safety investigations. Errors had various causes and multiple points of origin (e.g., foodservice system, staff). Intervention types included training, technology, checklists, and policies. The success of interventions was not reported, and the authors recommend additional research on the effectiveness of interventions.
Tsang JY, Sperrin M, Blakeman T, et al. BMJ Open. 2024;14:e081698.
Polypharmacy can increase medication complexity and lead to medication errors or adverse drug events (ADEs). This scoping review examined how polypharmacy is defined, identified, and addressed across 157 articles. The authors concluded that there is no consensus definition for polypharmacy. The authors also identified considerable variability in the types of interventions used to address polypharmacy, with studies covering a wide range of aims (e.g., reducing ADEs or patient falls, or improving adherence).
Braverman A. AORN Journal. 2024;119:421-427.
Briefings and time-outs prior to surgical procedures ensure that team members have a shared understanding of the plan and potential risks. This article describes how adding a visual component to surgical briefings, such as projecting the checklist onto a wall for all team members to see, can increase the surgical team's attention.
Moyal-Smith R, Elam M, Boulanger J, et al. Jt Comm J Qual Patient Saf. 2024;Epub Apr 23.
Ambulatory safety nets (ASNs) employ a combination of approaches (e.g., patient navigators, care coordination, patient education, workflow redesigns) to enhance the safety of patients receiving outpatient care. This article describes the design and execution of a colorectal cancer (CRC) ASN to identify patients a previous abnormal CRC screen (documentation of a previous positive at-home CRC screening or overdue surveillance colonoscopy) and facilitate completion of follow-up testing. Among patients identified between October 2022 - February 2024, 40% were scheduled for a colonoscopy and 29% completed screening. 
Badgery-Parker T, Li L, Fitzpatrick E, et al. J Pediatr. 2024;272:114087.
Pediatric patients are at increased risk of medication errors compared to adults, and this study sought to determine if a child's age is associated with risk of medication error. There was little association between age and prescribing errors for ages 0-3 years, then increasing until around age 10. Administration errors were steady for ages 0-8 years, and then increased with age until 18 years. 
Raffel KE, Gershanik EF, Ranji SR. J Hosp Med. 2024;Epub Apr 23.
Inequities can negatively affect a wide array of health care actions, including diagnosis. This commentary tracks the components of the National Academy of Medicine (NAM) diagnostic process framework as how they can align with equity concerns to shape a method for examining inequalities within hospital-based acute care diagnostic activities. The authors discuss the role of individual hospitalists and specialty leadership to address systemic diagnostic process weaknesses that result in patient harm.

US Department of Health and Human Services. 2023-2024. 

Work toward zero harm in health care is gaining national attention in the United States. These webinars align with efforts by the National Action Alliance to Advance Patient and Workforce Safety. There have been seven videos in this series of offerings from the Alliance supporting its work to improve safety. Four upcoming sessions discussing alliance aims and diagnostic safety research are open for registration.

Geneva, Switzerland: World Health Organization; 2024. ISBN 9789240095458.

Comparative data can help to inform and motivate patient safety improvement efforts. This report uses the seven objectives of the Global Patient Safety Action Plan 2021–2030 to examine the impact of unsafe care worldwide and the status of plan objective implementation in the six regions of World Health Organization (WHO) member states. It shares implementation successes and suggests areas of continued focus to generate continued and innovative achievement in avoidable medical harm reduction.
Young EE, Kane J, Timmons K, et al. Diagnosis (Berl). 2024;11:186-191.
Diagnostic uncertainty can be difficult to communicate without harming patient trust. This qualitative study examined deterrents to effective sharing of clinician uncertainty with caregivers of children whose diagnosis has yet to be determined. Challenges to these conversations include lack of time, language discordance, and lack of clarity around the uncertainty concept. The diagnostic pause and visual patient education tools were suggested as strategies for improvement.
Pais C, Liu J, Voigt R, et al. Nat Med. 2024;Epub Apr 25.
Large language models (LLMs) are artificial intelligence (AI) based tools which are increasingly used in healthcare to improve clinical decision-making and patient safety. This article describes the MEDIC (medication direction copilot) system, which uses LMMs to reduce prescribing errors by improving medication direction-related communication. The researchers tested MEDIC within an existing pharmacy workflow and found that the tool led to a 3% reduction in direction-related near miss events.
Sendak MP, Liu VX, Beecy A, et al. J Am Med Inform Assoc. 2024;Epub May 20.
In 2022, the Food and Drug Administration (FDA) released new guidance which impacts how artificial intelligence-based clinical decision support (CDS) tools are reviewed and approved. This article explores the impact of these changes on CDS tools for sepsis care and how healthcare organizations can ensure safe, equitable use of CDS tools.