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.

Search All Content

Clear all filter(s)

Displaying 1 - 20 of 1040 Results

From battles to burnout: investigating the role of interphysician conflict in physician burnout.

Save to Library

Amick AE, Schrepel C, Bann M, et al. Acad Med. 2023;98:1076-1082.

Disruptive behaviors, including experiencing or witnessing coworker conflict, can lead to staff burnout and adverse events. In this study, emergency medicine and internal medicine physicians reported on conflicts with other physicians they'd experienced in the workplace. Participants reported feeling demoralized and burnt out after a conflict and brought those feelings to future interactions, priming the situation for additional conflict.

Weight estimation for drug dose calculations in the prehospital setting - a systematic review.

Save to Library

Wells M, Henry B, Goldstein L. Prehosp Disaster Med. 2023;38:471-484.

Inaccurate estimations of patient weight can lead to medication errors in the prehospital period. This systematic review of 9 studies concluded that there is insufficient evidence to assess the accuracy of weight estimation approaches used in the EMS setting or by paramedics, underscoring the need for additional, robust research in this area.

Harm Caused by Delays in Transferring Patients to the Right Place of Care.

Save to Library

Farnborough, UK: Healthcare Safety Investigation Branch; August 2023.

Handoffs between prehospital emergency medical services (EMS) providers and hospital emergency departments (EDs) can be suboptimal, which increases patient harm potential. This report examines National Health Service discharge delays. It suggests a systemic approach is needed to address flow and capacity factors that contribute to ineffective and unsafe interfacility discharge and transfer.

Understanding and Improving Diagnostic Safety in Ambulatory Care.

Save to Library

Rockville, MD: Agency for Healthcare Quality and Research; August 22, 2023.

The articulation of diagnostic error in the ambulatory setting is emerging. These newly released funding announcements seek proposals that focus on understanding the factors contributing to diagnostic error and strategies to improve diagnostic safety in the ambulatory care environment. The application deadline for both opportunities has passed.

Clinical pathway adherence and missed diagnostic opportunities among children with musculoskeletal infections.

Save to Library

Grubenhoff JA, Bakel LA, Dominguez F, et al. Jt Comm J Qual Patient Saf. 2023;49:547-557.

Clinical care pathways (CP) standardize care to ensure evidence-based practices are consistently followed. This study analyzed missed diagnostic opportunities (MDO) of pediatric musculoskeletal infections that could have been mitigated had the CP recommendations been adhered to. Misinterpretation of laboratory results was a critical contributor to MDO by both pediatric emergency providers and orthopedic consultants.

Prolonged DKA in Pregnancy: A Case of Communication Breakdown.

Save to Library

WebM&M Case August 30, 2023

A 31-year-old pregnant patient with type 1 diabetes on an insulin pump was hospitalized for euglycemic diabetic ketoacidosis (DKA). She was treated for dehydration and vomiting, but not aggressively enough, and her metabolic acidosis worsened over several days. The primary team hesitated to prescribe medications safe in pregnancy and delayed reaching out to the Maternal Fetal Medicine (MFM) consultant, who made recommendations but did not ensure that the primary team received and understood the information.

Clinicians' insights on emergency department boarding: an explanatory mixed methods study evaluating patient care and clinician well-being.

Save to Library

Loke DE, Green KA, Wessling EG, et al. Jt Comm J Qual Patient Saf. 2023;Epub Jul 2.

Quantitative studies have demonstrated that emergency department (ED) overcrowding and patient boarding contribute to adverse events. This study includes both qualitative and quantitative methods to understand how ED clinicians view the impact of boarding on their own well-being as well as patient safety. Key themes include clinician dissatisfaction and burnout, and high rates of verbal and physical abuse from boarding patients. Possible solutions included improved standardization of care, proactive planning, and culture change hospital-wide.

Women with large vessel occlusion acute ischemic stroke are less likely to be routed to comprehensive stroke centers.

Save to Library

Tariq MB, Ali I, Salazar‐Marioni S, et al. J Am Heart Assoc. 2023;12:e029830.

Delayed diagnosis and treatment of stroke leads to adverse patient outcomes. This cross-sectional study identified gender disparities in the treatment of patients with large vessel occlusion (LVO) acute ischemic stroke (AIS), with women being less likely to be routed directly to comprehensive stroke centers compared with men, despite having more significant stroke syndromes.

Incidence and severity of medication reconciliation discrepancies in trauma patients.

Save to Library

Dunbar EG, Massey AC, Lee YL, et al. Am Surg. 2023;89:3272-3274.

Medication reconciliation is an important care process anytime a patient transitions from one care setting to another, including emergency department to hospital admission. This study sought to determine the incidence of completed medication reconciliation for admitted trauma patients and the number of identified discrepancies. Of the 89 patients included in the study, more than a quarter did not receive an admission medication reconciliation (AMR), and of those with an AMR, 48% had at least one unintended discrepancy, indicating the importance of completing medication reconciliation for all admitted trauma patients.

Improving emergency medicine clinician awareness of prehospital-administered medications.

Save to Library

Kamta J, Fregoso B, Lee A, et al. Prehosp Emerg Care. 2023;Epub Jul 28.

Handoffs from emergency medical services (EMS) to the emergency department (ED) are vulnerable to communication errors due to the time-pressured environment. This study reports on the implementation of an electronic health record (EHR) tool that added pre-hospital medication administration to the ED triage note to reduce medication administration errors (MAE). Although most ED providers reported they "always" review the triage note, MAE rates did not improve following implementation.

Factors influencing the perception of feeling safe in pre-hospital emergency care: a mixed-methods systematic review.

Save to Library

Péculo‐Carrasco J‐A, Luque‐Hernández MJ, Rodríguez‐Ruiz H‐J, et al. J Clin Nurs. 2023;32:4473-4491.

Emergency medical services (EMS) and pre-hospital care present unique challenges to ensure the delivery of safe care. This systematic review, including both qualitative and quantitative studies, identified four dimensions influencing patient perceptions of safety in pre-hospital care – satisfactory response from the emergency medical system, competence of EMS personnel, the setting of care/environmental factors, and patients’ personal characteristics.

Deficiencies in Emergency Department Care for a Patient Who Died by Suicide at the John Cochran Division of the VA St. Louis Health Care System in Missouri.

Save to Library

Washington DC: Department of Veterans Affairs, Office of Inspector General; June 29, 2023. Report no. 22-01540-146.

This report analyzed a patient suicide at an emergency department and determined factors in the delay of care that contributed to patient harm. This report shares recommendations to address leadership failures and other deficiencies including poor screening and patient monitoring. Post-event gaps identified include poor root cause analysis, disclosure, and reporting activities.

"You just want to feel safe when you go to a healthcare professional:" intimate partner violence and patient safety.

Save to Library

Maras SA. Soc Sci Med. 2023;331:116066.

Intimate partner violence (IPV) victims and survivors frequently access healthcare, but don’t always receive trauma-informed care or referrals to IPV resources. This study asked IPV survivors what patient safety meant to them. They described it as care that contained: 1) compassionate and/or trauma-informed care; 2) physically safe spaces; and/or 3) a connection to social resources. Survivors described ways healthcare providers could improve IPV safety.

Denied abortion for a doomed pregnancy, she tells Texas court: 'There was no mercy'.

Save to Library

Simmons-Duffin S. Health Shots. National Public Radio. July 20, 2023.

The range of unintended consequences stemming from abortion restrictions are beginning to be documented. This news story highlights three incidents of physical and psychological patient harm resulting from lack of access to needed care during pregnancy.

Bandemia as a Harbinger of Stercoral Colitis and Impending Perforation.

Save to Library

WebM&M Case July 31, 2023

A 56-year-old woman presented to the emergency department (ED) with shaking, weakness, poor oral intake and weight loss, constipation for several days, subjective fevers at home, and mild pain in the chest, back and abdomen. An abdominal x-ray confirmed a large amount of stool in the colon with no free air and her blood leukocyte count was 11,500 cells/μL with 31% bands. She received intravenous fluids but without any fecal output while in the ED.

Failure to adhere to dietary restrictions leading to complications and poor follow-up.

Save to Library

WebM&M Case July 31, 2023

A 50-year-old unhoused patient presented to the Emergency Department (ED) for evaluation of abdominal pain, reportedly one day after swallowing multiple sharp objects. Based on the radiologic finding of an open safety pin or paper clip in the distal stomach, he was appropriately scheduled for urgent esophagogastroduodenoscopy and ordered to remain NPO (nothing by mouth) to reduce the risk of aspirating gastric contents.

A national analysis of ED presentations for early pregnancy and complications: implications for post-Roe America.

Save to Library

Goodwin G, Marra E, Ramdin C, et al. Am J Emerg Med. 2023;70:90-95.

When the US Supreme Court overturned Roe v. Wade, access to safe reproductive care was restricted even for patients with wanted or non-viable pregnancies. This study describes trends in early pregnancy-related emergency department visits prior to the court decision and how new restrictions have resulted in physician uncertainty and delays in care in states with abortion bans. The authors recommend physicians be mindful of Emergency Medical Treatment and Active Labor Act (EMTALA) when caring for pregnant individuals in the emergency department.

Emergency lights and sirens on ambulances may do more harm than good.

Save to Library

Renault M. Stat. July 7, 2023.

Emergency vehicle transport can be dangerous for the patient, the clinician team, and the community. This article discusses the effect of ambulance use of alarm sirens on the safety of the service. Impacts such as psychological health of the patient and access to care units, should a crash occur, are discussed.

Patient perceptions and experiences with medication-related activities in the emergency department: a qualitative study.

Save to Library

Zahl-Holmstad B, Garcia BH, Johnsgård T, et al. BMJ Open Qual. 2023;12:e002239.

Designated emergency department (ED) pharmacists are increasingly used to improve the quality of medication administration in the ED. This qualitative study explored patient perceptions of medication safety before and during an ED pharmacist-led intervention (including medication reconciliation and medication review) in collaboration with ED physicians. Participants underscored the importance of trust and responsibility but noted that it was not important who carried out these medication-related tasks, but rather that the participant received the help they needed.

Evidence for anchoring bias during physician decision-making.

Save to Library

Ly DP, Shekelle PG, Song Z. JAMA Intern Med. 2023;183:818-823.

Anchoring bias is the tendency to focus on an initial diagnosis despite later evidence to the contrary. This study measured physicians’ potential anchoring bias regarding patients with congestive heart failure (CHF) with shortness of breath presenting to the emergency department. When the patient’s initial triage note included CHF, physicians were less likely and/or slower to test for pulmonary embolism (PE) than when the triage note did not mention CHF. This suggests physicians may have been subject to anchoring bias.

The PSNet Collection: All Content

Search All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

The PSNet Collection: All Content

Search All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site