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 263 Results

Walking Out of a Hospital After Attempted Suicide.

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WebM&M Case September 27, 2023

A 42-year-old man with a history of posttraumatic stress disorder (PTSD), alcohol use disorder and anxiety disorder, was seen in the emergency department (ED) after a high-risk suicide attempt by hanging. The patient was agitated and attempted to escape from the ED while on an involuntary psychiatric commitment. The ED staff treated him as a “routine boarder” awaiting an inpatient bed, with insufficiently robust behavioral monitoring.

Fragmented: A Doctor's Quest to Piece Together American Health Care.

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Yurkiewicz I. New York, NY: WW Norton & Company, Inc; 2023. ISBN: 9780393881196.

Disjointed health care processes contribute to missed test results, incomplete communication, and care omissions that harm patients. This book shares a personal account of how broken care processes serve as a core deterrent in one clinician’s ability to provide the safest care possible.

Only 1 in 5 people with opioid addiction get the medications to treat it, study finds.

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Mann B. Health Shots. National Public Radio. August 7, 2023.

Stigma against behavioral health conditions is known to affect the quality of care relationships and therapeutic actions. This news article discusses the limited use of methadone and other medications as strategies to assist in the care and recovery of opioid use disorder patients.

Supporting carers to improve patient safety and maintain their well-being in transitions from mental health hospitals to the community: a prioritisation nominal group technique.

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McMullen S, Panagioti M, Planner C, et al. Health Expect. 2023;26:2064-2074.

Caregivers and family members offer a unique perspective on patient safety. In this study, patient and caregiver stakeholders outlined the safety threats affecting patients discharged from mental health services and the well-being of caregivers as well as potential solutions. Participants highlighted approaches to improve caregiver involvement, patient and caregiver wellness and education, and the policy and system environments.

Why stigma matters in addressing alcohol harm.

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Morris J, Schomerus G. Drug Alcohol Rev. 2023;42:1264-1268.

Stigma and bias in healthcare undermine patient safety. This article discusses how stigma associated with alcohol use can impede the delivery of quality health care and contribute to poor patient outcomes.

Associations between self-reported healthcare disruption due to COVID-19 and avoidable hospital admission: evidence from seven linked longitudinal studies for England.

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Green MA, McKee M, Hamilton OKL, et al. BMJ. 2023;328:e075133.

Many patients were unable to access care during the pandemic, particularly during surges. This longitudinal cohort study in the UK reports that 35% of participants reported disrupted access to care (e.g., cancelled or postponed appointments or procedures). While overall rates of potentially preventable hospitalization were low (3%), those who reported disrupted access had increased risk of potentially preventable hospitalization.

The impact of primary care providers' bias on depression screening for lesbian women.

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Sha S, Aleshire M. Health Promot Pract. 2023;24:536-545.

Regular depression screening is recommended for all adults. Using a clinical vignette, the sexuality Implicit Association Test (IAT), and measures of explicit bias, this study examined the relationship of primary care providers' (PCP) bias towards lesbian women and recommendations for depression screening. Providers who recommended screening showed slightly more positive explicit attitudes and slightly lower, though not statistically significant, implicit bias towards lesbian women. However, recommendation rates among all providers were low, at only 38%.

Racism in health services for adolescents: a scoping review.

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Hilario C, Louie-Poon S, Taylor M, et al. Int J Soc Determinants Health Health Serv. 2023;53:343-353.

Structural racism is increasingly recognized as a social determinant of health. This systematic review identified 13 articles on the impact of racism on racialized adolescents. Most articles focused on the impact of racism on healthcare access and utilization, and in general or mental health care. Research into multiple forms of racism (i.e., institutional, interpersonal, internalized) and development and incorporation of robust measures of racism is needed to advance the field.

A Complicated Course: Severe Alcohol Withdrawal with Dexmedetomidine Infusion.

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WebM&M Case July 31, 2023

This case describes a 65-year-old man with alcohol use disorder who presented to a hospital 36 hours after his last alcoholic drink and was found to be in severe alcohol withdrawal. The patient’s Clinical Institute Withdrawal Assessment (CIWA) score was very high, indicating signs and symptoms of severe alcohol withdrawal. He was treated with symptom-triggered dosing of benzodiazepines utilizing the CIWA protocol and dexmedetomidine continuous infusion.

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

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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.

Using failure mode and effect analysis to identify potential failures in a psychiatric hospital emergency department.

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Gur-Arieh S, Mendlovic S, Rozenblum R, et al. J Patient Saf. 2023;19:362-368.

Failure mode and effect analysis (FMEA) is a common way to identify error risk. In this study, FMEA was used in a psychiatric hospital emergency department (ED) to identify potential failures. FMEA was completed by two groups, ED staff and non-ED staff, to determine if a multi-professional team could be used for the FMEA process. The groups’ ratings were very similar, indicating a multi-professional team can effectively complete an FMEA.

Racial and ethnic bias in the diagnosis of alcohol use disorder in veterans.

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Vickers-Smith R, Justice AC, Becker WC, et al. Am J Psych. 2023;180:426-436.

Racial and ethnic biases can affect diagnosis and negatively impact patient safety. Based on a sample of over 700,000 veterans, this study found that Black and Hispanic individuals consumed similar amounts of alcohol to White individuals but were more likely to be diagnosed with alcohol use disorder (AUD).

‘I felt like I was dying’: how women with postpartum depression fall through the cracks of U.S. health care.

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Gammon K. STAT. June 26, 2023.

The maternal mental health crisis results in harm to mothers and their families. This article discusses systemic issues that impact the safe psychological care of mothers from pregnancy through the years of caring for toddlers. Lack of timely diagnosis is a major consideration discussed.

Deficient Care of a Patient Who Died by Suicide and Facility Leaders' Response at the Charlie Norwood VA Medical Center in Augusta, Georgia.

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Washington DC: Department of Veterans Affairs, Office of Inspector General; May 10, 2023. Report no. 22-01116-110.

Death of a patient by suicide is a sentinel event. This report examined one incident and identified care deficiencies associated with lack of mental health referrals and pain management follow-up. In addition, post-event process gaps occurred, impacting learning and resolution such as a delay in the inquiry launch, peer review, and clinical review of the incident. Claims that the facility purposely sought to hide information that the suicide happened were unsubstantiated.

Systems approach to suicide prevention: strengthening culture, practice, and education.

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Pisani AR, Boudreaux ED. Focus (Am Psychiatr Publ). 2023;21:152-159.

Identifying patients with suicidal ideation can be a challenging clinical problem in the emergency department. These authors use a systems-based approach to identify missed opportunities to prevent suicide and present a systems approach to suicide prevention including three core domains – a culture of safety and prevention, applying best practices and policies for prevention in systems, and workforce education and development.

Understanding the medication safety challenges for patients with mental illness in primary care: a scoping review.

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Ayre MJ, Lewis PJ, Keers RN. BMC Psychiatry. 2023;23:417.

Medication safety in inpatient and outpatient settings is a major focus of patient safety efforts. This review included 79 studies on epidemiology, etiology, or interventions related to psychiatric medication safety in primary care (e.g., general practice, community pharmacy, long-term care). Most studies focused on older adults and potentially inappropriate prescribing. The authors recommend future research on wider age groups and underrepresented mental health diagnosis, such as attention deficient hyperactivity disorder (ADHD).

The One That Got Away—Elopement of a Suicidal Patient in the Emergency Department.

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WebM&M Case June 14, 2023

A 25-year-old female was sent by ambulance to the emergency department (ED) by a mental health clinic for suicidal ideation. Upon arrival to the ED, she was evaluated by the triage nurse and determined to be awake, alert, calm, and cooperative and she denied current suicidal thoughts. The ED was extremely busy, and the patient was placed on a gurney with a Posey restraint in the hallway next to the triage station awaiting psychiatric social work assessment. Approximately 40 minutes later, the triage nurse noticed that the patient was missing from the gurney.

Effect of an emergency department process improvement package on suicide prevention: the ED-SAFE 2 cluster randomized clinical trial.

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Boudreaux ED, Larkin C, Vallejo Sefair A, et al. JAMA Psych. 2023;80:665-674.

Patients who present to the emergency department (ED) with suicidal ideation can benefit from ED-initiated interventions, but interventions can be difficult to implement and maintain. This research builds on a 2013 study, describing the quality improvement (QI) methods used to implement the Emergency Department Safety Assessment and Follow-up Evaluation 2 (ED-SAFE 2) trial. The QI approach was successful in reducing death by suicide and suicide-related acute care during the study period.

Analysis of reported suicide safety events among veterans who received treatment through Department of Veterans Affairs-contracted community care.

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Riblet NB, Soncrant C, Mills PD, et al. Mil Med. 2023;188:e3173-e3181.

Patient suicide is a sentinel event, and suicide among veterans has gained attention. In this retrospective analysis of suicide-related events reported to the Veterans Health Administration (VHA) National Center for Patient Safety between January 2018 and June 2022, researchers found that deficiencies in mental health treatment, communication challenges, and unsafe environments were the most common contributors to suicide-related events.

Structural racism in behavioral health presentation and management.

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Rainer T, Lim JK, He Y, et al. Hosp Pediatr. 2023;13:461-470.

Structural racism and implicit biases can affect clinical judgement and impede the delivery of effective mental health care. Based on a case of an adolescent Black girl navigating through the pediatric behavioral health system, this article discusses how structural racism and health disparities in behavioral health care contributed to misdiagnosis and poor care. The authors outline several actions at the structural, institutional, and interpersonal levels to address racism’s impact on pediatric mental and behavioral healthcare.

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