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 4098 Results

Preventing potential patient harm through clinical content interventions during oncology clinical trial implementation.

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Loo VC, Kim S, Johnson LM, et al. J Patient Saf. 2023;19:460-464.

Ensuring the safety of clinical trial participants is paramount to successful, meaningful clinical research. In this study, researchers examined 585 clinical trial documents and found that 17% included potential patient safety interventions (e.g., resolving medication dosing discrepancies). The authors suggest that clinical specialists’ review of study protocol documents could enhance patient safety during clinical trial conduct.

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

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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.

Do not PIMP my nursing home ride! The impact of Potentially Inappropriate Medications Prescribing on residents' emergency care use.

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Rapp T, Sicsic J, Tavassoli N, et al. Eur J Health Econ. 2023;24:1085-1100.

Potentially inappropriate prescribing in long-term care facilities increases the risk of adverse drug events and other adverse outcomes, including increased healthcare costs. Based on a secondary data analysis from the Systematic Dementia Screening by Multidisciplinary Team Meetings in Nursing Homes for Reducing Emergency Department Transfers (IDEM) randomized trial, this study found that increases in potentially inappropriate prescribing increased residents’ risk of going to the emergency room and increased total medication spending.

Patient and family contributions to improve the diagnostic process through the OurDX electronic health record tool: a mixed method analysis.

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Bell SK, Harcourt K, Dong J, et al. BMJ Qual Saf. 2023;Epub Aug 21.

Patient and family engagement is essential to effective and safe diagnosis. OurDX is a previsit online engagement tool to help identify opportunities to improve diagnostic safety in patients and families living with chronic conditions. In this study, researchers implemented OurDX in specialty and primary care clinics at two academic healthcare organizations and examined the potential safety issues and whether patient/family contributions were integrated into the post-visit notes. Qualitative analysis of 450 OurDX reports found that participants contributed important information about the diagnostic process. Participants with diagnostic concerns were more likely to raise concerns about the diagnostic process (e.g., access barriers, problems with tests/referrals, communication breakdowns), which may represent diagnostic blind spots.

Physician perspectives on responding to clinician-perpetuated interpersonal racism against Black patients with serious illness.

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Brown CE, Snyder CR, Marshall AR, et al. J Gen Intern Med. 2023;Epub Aug 24.

Structural racism continues to perpetuate health disparities. As part of their study on how black patients with serious illness experience racism from providers, researchers conducted interviews with 21 providers to understand ways they address anti-Black racism in their practice. Providers felt unprepared to address racism with their patients, wanted to provide tools for patients to bring up their experiences while also acknowledging the additional burden this would place on Black patients, and thought patient- and provider-facing programs could facilitate discussions. Additionally, despite extensive research on the negative impacts of structural racism on health, participants cited the need for more data.

Healthcare leaders' and elected politicians' approach to support-systems and requirements for complying with quality and safety regulation in nursing homes - a case study.

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Magerøy MR, Braut GS, Macrae C, et al. BMC Health Serv Res. 2023;23:880.

Ensuring staff have a safe work environment and patients receive safe care are separate but complementary goals. This study describes how elected politicians and healthcare leaders balance workplace safety regulations and patient quality and safety goals in long-term care facilities. Tensions between the groups were identified (e.g., where leaders see flexibility, elected leaders see vagueness). Study themes include creating and improving channels for communication, and clear delineation of roles and responsibilities.

Handling polypharmacy--a qualitative study using focus group interviews with older patients, their relatives, and healthcare professionals.

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Mikkelsen TH, Søndergaard J, Kjaer NK, et al. BMC Geriatr. 2023;23:477.

Older adults taking 5 or more medications daily (i.e., polypharmacy) face numerous challenges to taking them safely. In this study, patients, caregivers, and clinicians describe methods to taking medications safely, difficulties they face, and ways prescribers and pharmacists can assist patients. Medication reviews, a common strategy to ensure safe polypharmacy, were requested by patients to clear up confusion around generics, timing, limitations, and side effects.

Annual Diagnostic Excellence Summit.

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The Armstrong Institute Center for Diagnostic Excellence. Johns Hopkins University, Baltimore, MD, September 27, 9:00 AM-4:00 PM (eastern).

Advanced computer technologies and data analysis are an increasing focus in diagnostic safety efforts. The theme of this annual event is “Diagnostic Digital Health Research”. Ethical use of artificial intelligence, consumer diagnostic technology and digital diagnostics and amongst the topics to be covered.

Potentially inappropriate medication use is associated with increased risk of incident disability in healthy older adults.

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Lockery JE, Collyer TA, Woods RL, et al. J Am Geriatr Soc. 2023;71:2495-2505.

Potentially inappropriate medications (PIM) are a known contributor to patient harm in older adults. In contrast to most studies of PIM in patients with comorbid conditions or residing in hospitals or nursing homes, this study evaluated the impact of PIM use in community-dwelling older adults without significant disability. Participants with at least one PIM were at increased risk of physical disability and hospitalization over the study period (8 years) than those not taking any PIM. However, both groups had similar rates of death.

Understanding and Improving Diagnostic Safety in Ambulatory Care.

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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.

The e-Autopsy/e-Biopsy: A Systematic Chart Review to Increase Safety and Diagnostic Accuracy Innovation

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Patient Safety Innovation August 30, 2023

Addressing diagnostic errors to improve outcomes and patient safety has long been a problem in the US healthcare system.¹ Many methods of reducing diagnostic error focus on individual factors and single cases, instead of focusing on the contribution of system factors or looking at diagnostic errors across a disease or clinical condition. Instead of addressing individual cases, KP sought to improve the disease diagnosis process and systems. The goal was to address the systemic root cause issues in systems that lead to diagnostic errors.

Prolonged DKA in Pregnancy: A Case of Communication Breakdown.

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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.

Exploring the impact of safety culture on incident reporting: lessons learned from machine learning analysis of NHS England staff survey and incident data.

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Kaya GK, Ustebay S, Nixon J, et al. Safety Sci. 2023;166:106260.

Voluntary incident reporting rates may be an indicator of organizational safety culture. Using different machine learning algorithms, this study found that several components of safety culture – compassionate culture, violence and harassment, and work pressure – have a significant impact on predicting incident reporting behavior.

Estimating breast cancer overdiagnosis after screening mammography among older women in the United States.

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Richman IB, Long JB, Soulos PR, et al. Ann Intern Med. 2023;176:1172-1180.

Overdiagnosis can result in overtreatment, physical harm, and emotional distress. Using SEER-Medicare data, researchers examined breast cancer overdiagnosis by comparing cancer incidence among women who discontinued mammography screening after age 70 compared to women who continued to receive screening mammograms. Findings suggest that breast cancer may be potentially overdiagnosed among 31% of women aged 70 to 74 years, 47% of women aged 75 to 84 years, and 54% of women aged 85 and older who continue to receive screening mammograms.

Compliance with central line maintenance bundle and infection rates.

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Tripathi S, McGarvey J, Lee K, et al. Pediatrics. 2023;152:e2022059688.

Reducing central line-associated bloodstream infections (CLABSI) is an important patient safety improvement target. This study examined the relationship between compliance with evidence-based CLABSI guideline bundles and CLABSI rates in 159 hospitals. Between 2011 and 2021, researchers found that adherence to bundle guidelines was associated with a significant reduction in CLABSI rate.

Cognitive biases and moral characteristics of healthcare workers and their treatment approach for persons with advanced dementia in acute care settings.

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Erel M, Marcus E-L, DeKeyser Ganz F. Front Med (Lausanne). 2023;10:1145142.

Cognitive biases can influence treatment approach at the end of life. The goal of this study was to determine whether treatment approaches (e.g., palliative care to aggressive treatment) were associated with clinician cognitive biases in acute care settings for patients with advanced dementia and comorbidities. Representativeness, availability, and anchoring biases were associated with treatment approach in this hypothetical patient case; moral characteristics of the clinician were not associated with treatment approach.

Unpacking the complexity of COVID-19 fatalities: adverse events as contributing factors--a single-center, retrospective analysis of the first two years of the pandemic.

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Zińczuk A, Rorat M, Simon K, et al. Viruses. 2023;15:1430.

The COVID-19 pandemic exacerbated many existing patient safety challenges. This retrospective analysis of 477 fatal COVID-19 cases at one hospital in Poland found that one-third of patients experienced a healthcare-acquired infection during their hospitalization as well as other hospital-acquired complications, including thrombolytic and/or bleeding complications, acute kidney injury, and exacerbation of chronic heart disease. The analysis also found that many patients experienced delays in specialist treatment (33%) or lack of specialist treatment (17%) during their hospitalization.

Value assessment of deprescribing interventions: suggestions for improvement.

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Hung A, Wang J, Moriarty F, et al. J Am Geriatr Soc. 2023;71:2023-2027.

Deprescribing is used to reduce the risk of adverse drug events resulting from polypharmacy among older adults. This article outlines several recommendations for improved cost-effectiveness analyses of deprescribing interventions to support decision makers.

American Geriatrics Society 2023 updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.

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American Geriatrics Society Beers Criteria® Update Expert Panel. J Am Geriatr Soc. 2023;71(7):2052-2081.

Inadvertent overprescribing and polypharmacy in the 65-year old or older patient population is a contributor to patient harm. The Beers criteria serve as standard guidance for clinicians to prevent the potential for Inappropriate medication prescribing. This guideline updates existing recommendations and simplified the listing by removing rarely used medications in the geriatric population.

The impact of transition to a digital hospital on medication errors (TIME study).

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Engstrom T, McCourt E, Canning M, et al. NPJ Digit Med. 2023;6:133.

Computerized provider order entry (CPOE), clinical decision support (CDS), and other technologies can reduce prescribing errors, but their initial implementation may present new errors. This study reports prescribing errors before and after transition to digital hospital records. Results show significant decreases in prescribing errors after transition, but also identified new problems, such as alert fatigue, that needed additional attention to remediate.

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