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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 80 Results
Patient Safety Innovation May 31, 2023

Patient falls in hospitals are common and debilitating adverse events that persist despite decades of effort to minimize them. Improving communication across the assessing nurse, care team, patient, and patient’s most involved friends and family may strengthen fall prevention efforts. A team at Brigham and Women’s Hospital in Boston, Massachusetts, sought to develop a standardized fall prevention program that centered around improved communication and patient and family engagement.

Hessels AJ, Guo J, Johnson CT, et al. Am J Infect Control. 2023;51:482-489.
Standard precautions, including hand hygiene and sharps safety, keep patients and staff safe, but adherence is suboptimal. An earlier systematic review shows an association between standard precaution compliance and overall safety climate. This study aimed to determine if adherence to standard precautions and safety climate were associated with healthcare associated infection (HAI) rates. Adherence rates were low (64%) and associated with HAI and healthcare worker needlesticks.
Perspective on Safety April 26, 2023

Throughout 2022, AHRQ PSNet has shared research that elucidates the complex nature of misdiagnosis and diagnostic safety. This Year in Review explores recent work in diagnostic safety and ways that greater safety may be promoted using tools developed to improve diagnostic practices.

Throughout 2022, AHRQ PSNet has shared research that elucidates the complex nature of misdiagnosis and diagnostic safety. This Year in Review explores recent work in diagnostic safety and ways that greater safety may be promoted using tools developed to improve diagnostic practices.

Curated Libraries
October 10, 2022
Selected PSNet materials for a general safety audience focusing on improvements in the diagnostic process and the strategies that support them to prevent diagnostic errors from harming patients.

Zimolzak AJ, Singh H, Murphy DR, et al. BMJ Health Care Inform. 2022;29(1):e100565.

Patient safety algorithms developed through research must also be implemented into clinical practice. This article describes the process of translating an electronic health record-based algorithm for detecting missed follow-up of colorectal or lung cancer testing, from research into practice. All 12 test sites were able to successfully implement the trigger and identify appropriate cases.
Brown L. Diagnosis (Berl). 2020;7:83-84.
This editorial describes one clinician’s experience treating a patient during the early stages of the COVID-19 pandemic, and the impacts of “COVID blindness” and anchoring bias, which resulted in delayed sepsis treatment for this patient.
Weingart SN, Yaghi O, Barnhart L, et al. Appl Clin Inform. 2020;11.
To decrease the risk of diagnostic errors attributed to incomplete recommended diagnostic tests, this study evaluated an electronic monitoring tool alerting clinicians to incomplete imaging tests for their ambulatory patients. Compared to the control group (physicians not receiving alerts for their patients), after 90-days the intervention group had a higher rate of imaging completion (22.1% vs. 18.8%); this difference was sustained throughout the 12-month follow-up period (25.5% completion in the intervention group versus 20.9% in the control group). The authors found that this change was primarily driven by completion rates among patients referred for mammography.  To fully appreciate the implications of missed test notifications to reduce the risk of delayed diagnoses, more studies are necessary.
Sacarny A, Barnett ML, Agrawal S. NEJM Catalyst. April 10, 2019.
Overprescribing contributes to polypharmacy, antibiotic resistance, and opioid misuse. This commentary discusses strategies to change prescriber behavior such as peer comparisons and opioid overdose letters to prescribers whose patients recently overdosed to drive improvement and reflection.
Ellison RT, Barysauskas CM, Rundensteiner EA, et al. Open Forum Infect Dis. 2015;2:ofv121.
Hand hygiene remains one of the most basic targets for enhancing patient safety. Poor hand hygiene compliance persists despite multiple global efforts, and a recent study showed handwashing rates are likely even lower when there is not a direct observer recording compliance. This prospective controlled trial in two medical intensive care units (ICUs) studied the effect of an electronic reminder system. An audible chime for each room entry and exit initially increased handwashing events in the test ICU, but this effect quickly declined, likely related to alert fatigue. In contrast, a combination of a chime and real-time computer monitor feedback of current hygiene compliance rates resulted in an increase that lasted throughout the study phase. Once the reminder system was turned off, compliance rates returned to the previous baseline. Overall hand hygiene compliance rates were quite low: recorded handwashing occurred in only about one-third of room entries or exits. A prior AHRQ WebM&M perspective reviewed innovations in promoting hand hygiene compliance.
Davis R, Parand A, Pinto A, et al. J Hosp Infect. 2015;89:141-62.
Hand hygiene is critical to prevention of health care–associated infections. Despite intensive efforts, hand hygiene is not practiced universally in clinical settings. This systematic review sought to evaluate the effectiveness of patient-focused interventions to enhance adherence to hand hygiene practices. Researchers examined studies aimed at encouraging patients to remind health care providers to wash their hands. Because of the limited number and quality of current studies, researchers were unable to draw firm conclusions. Encouragement from health care providers seemed to be an important predictor for success in empowering patients to speak up about hand hygiene concerns. The authors recommend conducting more methodologically rigorous studies in order to determine the impact of patient-focused initiatives to promote hand hygiene. A recent AHRQ WebM&M perspective discussed strategies to enhance hand hygiene compliance.
Ryan R, Santesso N, Lowe D, et al. Cochrane Database Syst Rev. 2014:CD007768.
This review describes how researchers identified and analyzed systematic reviews on interventions to augment safe medication use. The authors provide an overview of safety improvement strategies, such as reminders and financial incentives. Medication self-management programs generally enhanced medication safety and health outcomes, but more research is needed for clinically complex populations and technology-enabled strategies.
WebM&M Case July 1, 2011
A man with HIV disease and a recent diagnosis of CNS toxoplasmosis presented to the ED for the third time in two weeks with headaches, seizures, and right-sided weakness. Physicians pursued a workup for treatment-resistant toxoplasmosis or another brain disease, but discovered that the patient had run out of his toxoplasmosis medications.
Schnipper JL, Liang CL, Hamann C, et al. J Am Med Inform Assoc. 2011;18:309-13.
Efforts to prevent medication-related adverse events after hospital discharge have largely focused on medication reconciliation at the time of discharge. This study reports on the early experience with a medication reconciliation tool for use by primary care physicians after discharge. Although initial uptake was low, the study reports on many lessons learned through initial implementation.