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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 47 Results
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.

Rockville, MD: Agency for Healthcare Research and Quality; October 2022.

Inappropriate antibiotic prescribing is associated with increased risk potential. This toolkit assists in simplifying the antibiotic decision-making process. It is organized around a four-point decision aide and contains resources on using a stewardship program, communicating about prescribing and applying best practices for common infectious diseases.
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.
Oyegoke S, Gigli KH. J Patient Saf. 2022;18:e753-e759.
Strong safety culture is a crucial pillar of patient safety improvement efforts. Based on data from the Medical Office Survey on Patient Safety Culture, this study found that staff in pediatric primary care settings had generally positive perceptions about safety culture. Researchers identified differences in perceptions based on staff role, such as between administration/management staff and direct care staff.
Carvalho IV, Sousa VM de, Visacri MB, et al. Pediatr Emerg Care. 2021;37:e152-e158.
This study sought to determine the rate of pediatric emergency department (ED) visits due to adverse drug events (ADE). Of 1,708 pediatric patients, 12.3% were admitted to the ED due to ADEs, with the highest rates of admission due to neurological, dermatological, and respiratory medications. The authors recommend the involvement of clinical pharmacists to prevent and identify ADEs in the pediatric population, particularly through education of children’s caregivers and health professionals.
Toce MS, Michelson K, Hudgins J, et al. JAMA Pediatr. 2020;74:961-968.
This study explored the association of state-level opioid-reduction policy implementation (a prescription drug monitoring program [PDMP], pain clinic legislation, and opioid prescribing guidelines) with rates of pediatric opioid poisoning in New York. PMDP implementation and pain clinic legislation were both associated with reductions in opioid poisoning rates for most age groups. Analyses of prescribing guidelines did not show a change in the rate of opioid poisoning.
Reaume M, Farishta M, Costello JA, et al. Postgrad Med J. 2020;97:55-58.
Point-of-care ultrasounds (POCUS) are considered a powerful tool to enhance patient safety through expedited diagnosis, but also present safety threats. There is a concern that POCUS use may contribute to diagnostic error lawsuits. The authors reviewed lawsuits involving the diagnostic use of POCUS in internal medicine, pediatrics, family medicine, and critical care and did not find any cases of physicians in these specialties being subject to adverse legal action for the diagnostic use of POCUS.   
Omar A, Rees P, Cooper A, et al. Arch Dis Child. 2020;105:731-777.
Using a national database of patient safety incident reports in the United Kingdom, this study characterized primary care-related incidents among vulnerable children and used thematic analysis to identify priority areas for systems improvement. Over 1,100 incident reports were identified; nearly half resulted in some degree of harm but most (39%) were considered ‘low harm.’ Children with  protection-related vulnerabilities experienced harm from unsafe care more frequently than children with social-, psychological, or physical vulnerabilities. The authors identified system priority action areas to mitigate harm among vulnerable children, including improving provider access to accurate information and reducing delays in provider referrals.
Gilleland J, Bayfield D, Bayliss A, et al. BMJ Open Qual. 2019;8:e000763.
Early warning systems and trigger tools are frequently used in inpatient settings to identify clinical deterioration and prevent adverse events in pediatric populations, but their use in community settings to improve illness detection and time to treatment is less common. The article discusses a consensus workshop, the goal of which was to develop the “severe illness getting noticed sooner” (SIGNS-for-kids) tool to empower parents and caregivers by identifying specific cues of severe illness in infants and children. The panel, comprised of parents and healthcare experts, identified five cues: (1) behavior, such as reduced interaction or lack of movement, (2) breathing, including noticeable breathing or long pauses between breaths, (3) skin, such as jaundice or blueish skin/tongue, (4) fluids, such as persistent vomiting or lack of urine, and (5) response to rescue treatments, or deterioration despite use of usually effective treatment.
Cohen SP, Pelletier JH, Ladd JM, et al. J Gen Intern Med. 2019;11:226-230.
The Accreditation Council for Graduate Medical Education (ACGME) created the Clinical Learning Environment Review (CLER) program to evaluate teaching institutions in six focus areas, including patient safety. This article summarizes the impact of a Pediatric Residency Safety Council (PRSC) initiative on resident event reporting and safety attitudes. Over a five-year period, there was an increase in the percentage of residents who felt that could submit a safety report, but there was not a significant increase in the number of reports submitted. The authors propose that a resident-led council can help incorporate the CLER patient safety pathways into resident training programs. A PSNet Primer discusses the importance of debriefing in patient safety events.
Solodiuk JC, Greco CD, O'Donnell KA, et al. J Pediatr Nurs. 2019;49:18-23.
Improvement strategies are important for systems to implement in order to improve medication safety in children.  This study found that a post-PICU sedation weaning guideline can reduce the number of children discharged on medications such as opioids, benzodiazepines, and methadone without increasing the incidence of severe withdrawal symptoms or length of stay. 

Rathore MH, Jackson MA, AAP Committee on Infections Diseases. Pediatrics. 2017;140(5):e20172857.

Patient safety in the ambulatory environment has received less attention than hospital settings. This guideline provides recommendations to reduce transmission of infectious agents in pediatric ambulatory care, such as policy review and development, education for personnel, and hand hygiene precautions.
Barry E, O'Brien K, Moriarty F, et al. BMJ Open. 2016;6:e012079.
Although certain medication classes pose increased risks to children, well-defined criteria for potentially inappropriate prescribing for pediatric patients have not been established. This study described an iterative consensus-building process which identified 12 indicators of potentially inappropriate medications for children. Future studies will test the validity of these indicators.
Wood JN, French B, Song L, et al. Pediatrics. 2015;136:232-40.
This study assessed an error of omission—failure to assess children for occult fractures—in several clinically indicated situations, and found that such errors occur in about half of cases. Interventions to prompt specific actions, like checklists, may be useful in this clinical arena.

Brega AG, Barnard J, Mabachi NM, et al. Rockville, MD: Agency for Healthcare Research and Quality; January 2015. AHRQ Publication No. 15-0023-EF.

The AHRQ Health Literacy Universal Precautions Toolkit, 2nd edition, can help primary care practices implement improvement actions to reduce the complexity of health care, increase patient understanding of health information, and enhance support for patients of all health literacy levels.
Matlow A, Baker R, Flintoft V, et al. CMAJ. 2012;184:E709-718.
Hospitalized children are particularly vulnerable to specific types of errors, such as medication errors. This Canadian study used a trigger tool approach to estimate the frequency of all types of adverse events in hospitalized children, and found that nearly 1 in 10 pediatric patients suffers an adverse event while hospitalized. This prevalence is similar to classic studies performed in adult populations. Preventable adverse events, which accounted for approximately half of all events, were particularly common in children undergoing surgery or requiring intensive care. Diagnostic errors also accounted for a significant proportion of preventable adverse events. A preventable error in a critically ill 8-month-old child is discussed in an AHRQ WebM&M commentary.
Rappaport DI, Collins B, Koster A, et al. Pediatrics. 2011;128:e1600-7.
Medication reconciliation was initially established as a National Patient Safety Goal (NPSG) in 2005. However, difficulty establishing and implementing effective medication reconciliation approaches led to The Joint Commission suspending evaluation of this NPSG in 2009 and eventually eliminating it as a separate NPSG in 2011. This report from a large health care system provides a detailed template for integrating medication reconciliation into clinician workflow in the outpatient setting. Through a combination of leadership engagement, rapid cycle quality improvement projects, and financial incentives, the organization achieved consistent and sustained improvement in documentation of medication reconciliation for pediatric patients over a 5-year period. As medication reconciliation has been less studied in the ambulatory care setting, this study provides a useful window into the barriers inherent in changing outpatient clinician workflow and the steps this organization took to minimize unintended consequences of the intervention.
Gordon M, Melvin P, Graham DA, et al. Arch Pediatr Adolesc Med. 2011;165:424-8.
Improving teamwork and communication is a continued focus in the hospital setting. Targeted interventions to address noted gaps include adoption of interdisciplinary rounds, use of patient whiteboards, and structured tools such as SBAR. This study reorganized physicians into unit-based teams to evaluate the impact on nurse–physician communication. Following implementation of the new model, physicians were more likely to identify the nurse for their patients and experience increased frequency of direct communication with them. These changes also led to 42% fewer pages from nurses to physicians. While the study didn’t correlate these self-reported improvements in communication to clinical outcomes, it’s one of the first studies investigating the benefits of geographic organization as a potential safety strategy.
Kaushal R, Goldmann DA, Keohane CA, et al. BMJ Qual Saf. 2010;19.
Pediatric medication errors are common yet studied less in the ambulatory setting than in the inpatient arena. This prospective cohort study of six outpatient practices identified more than 1200 medication errors with minimal potential for harm, and more than 460 potentially harmful ones deemed near misses. Overall, a remarkable half of all prescriptions had errors and a fifth of those had potential for harm. The authors were particularly interested in understanding the differences between errors with minimal potential for harm and near misses. The prescribing stage was responsible for nearly 95% of the errors in the former category but only 60% of the latter. Whereas inappropriate abbreviations were the most common cause in the minimal harm group, dosing errors were most common in the near misses. Their findings suggest that e-prescribing may effectively address many of the issues identified, particularly around provider illegibility, but further solutions will also be needed.