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 21 - 40 of 16744 Results

Learning from diagnostic errors to improve patient safety when GPs work in or alongside emergency departments: incorporating realist methodology into patient safety incident report analysis.

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Cooper A, Carson-Stevens A, Cooke M, et al. BMC Emerg Med. 2021;21:139.

Overcrowding in the emergency department (ED) can result in increased frequency of medication errors, in-hospital cardiac arrest, and other patient safety concerns. This study examined diagnostic errors after introducing a new healthcare service model in which emergency departments are co-located with general practitioner (GP) services. Potential priority areas for improvement include appropriate triage, diagnostic test interpretation, and communication between GP and ED services.

Coronavirus Disease 2019 (COVID-19) and Diagnostic Error

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Patient Safety Primer January 11, 2022

Diagnostic error has been increasingly recognized as an important and evolving patient safety issue. This Primer applies well-established principles of diagnostic error and improvement of diagnostic accuracy to the topic of COVID-19.

Veterans Health Administration Stratification Tool for Opioid Risk Mitigation (STORM) Shows Promise for Targeting Prevention Interventions to Reduce Mortality in Patients Who Are Prescribed Opioids

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Patient Safety Innovation January 7, 2022

The Veterans Health Administration (VHA) Stratification Tool for Opioid Risk Mitigation (STORM) decision support system and targeted prevention program were designed to help mitigate risk factors for overdose and suicide among veterans who are prescribed opioids and/or with opioid use disorder (OUD) and are served by the VHA.¹ Veterans, particularly those prescribed opioids, experience overdose and suicide events at roughly twice

The Next Step: Use of a Pre-Operative Checklist to Prevent Missteps

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WebM&M Case January 7, 2022

A 52-year-old woman presented for a lumpectomy with lymphoscintigraphy and sentinel lymph node biopsy (SLNB) after being diagnosed with ductal carcinoma in situ (DICS). On the day of surgery, the patient was met in the pre-operative unit by several different providers (pre-operative nurse, resident physician, attending physician, and anethesiology team) to help prepare her for the procedure. In the OR, the surgical team performed two separate time-outs while the patient was being prepped, placed under general anesthesia, and draped.

Multiple Missed Opportunities for Suicide Risk Assessment in Emergency and Primary Care Settings

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WebM&M Case January 7, 2022

An 18-year-old man with a history of untreated depression and suicide attempts (but no history of psychiatric hospitalizations) was seen in the ED for suicidal ideation after recent gun purchase. Due to suicidal ideation, he was placed on safety hold and a psychiatric consultation was requested. The psychiatry team recommended discharge with outpatient therapy; he was discharged with outpatient resources, the crisis hotline phone number, and strict return precautions.

Improving allergy documentation: a retrospective electronic health record system-wide patient safety initiative.

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Li L, Foer D, Hallisey RK, et al. J Patient Saf. 2022;18:e108-e114.

Despite the introduction of computerized provider order entry into electronic health records, providers still frequently use free-text fields to communicate important information which introduces a patient safety risk. One healthcare system searched allergy-related free-text fields, identifying more than 242,000 entries. Approximately 131,000 were manually or automatically remediated (e.g., “latex from back brace” and “gloves” were coded “latex-natural rubber”).

ACS Quality Improvement Course: The Basics

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Organization: Organization American College of Surgeons (ACS)

Event Description: The self-paced, online course is intended for anyone working in a health care setting who is still learning the foundations of quality improvement, regardless of their role. It includes six modules: Introduction to Quality Improvement The Quality Improvement Process Data Measurement and Analysis Change Management Patient Safety Leadership and Teamwork for QI

Event Location: Online

Date: On Demand

Event Fee: Fee Associated

CE or CME Offered? Yes

Weblink: Weblink https://www.facs.org/quality-programs/about/qi-basics-course

Webinar Series

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Organization: Organization Institute for Safe Medication Practices (ISMP)

Event Description: ISMP's series of webinar on Safety topics. Most programs provide required medication/patient safety continuing education credits for pharmacists, pharmacy technicians, and nurses.

Event Location: Online

Date: On Demand

Event Fee: Free

CE or CME Offered? Yes

Weblink: Weblink https://www.ismp.org/events-webinars-and-workshops?field_event_type_target_id%5…

Next of kin involvement in regulatory investigations of adverse events that caused patient death: a process evaluation.

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Wiig S, Haraldseid-Driftland C, Tvete Zachrisen R, et al. J Patient Saf. 2021;17(8):e1707-e1718.

Families and next of kin are important partners in patient safety. In two Norwegian counties, next of kin who had lost a family member due to an adverse event participated in in-person meetings with inspectors as part of the regulatory investigation. This study explored the experiences and perspectives of the next of kin (Part 1) and regulatory inspectors (Part 2) involved in this new approach to next-of-kin involvement in regulatory investigations. Despite being an emotionally challenging process, next of kin viewed participation in the regulatory investigation as a positive experience and believed that their contributions improved the investigation process.

Association of surgeon-patient sex concordance with postoperative outcomes,

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Wallis CJD, Jerath A, Coburn N, et al. JAMA Surg. 2022;157:146-156.

Gender, racial, and ethnic disparities in healthcare can adversely impact patient safety and lead to poor outcomes. This retrospective study examined surgeon-patient sex discordance and perioperative outcomes among adult patients in Ontario, Canada, undergoing common elective or emergent surgical procedures from 2007 to 2019. Among 1.3 million patients, sex discordance between surgeon and patient was associated with a significant increased likelihood of adverse perioperative outcomes, including death. Subgroup analyses indicate that this relationship is driven by worse outcomes among female patients treated by male surgeons.

Association of differences in treatment intensification, missed visits, and scheduled follow-up interval with racial or ethnic disparities in blood pressure control.

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Fontil V, Pacca L, Bellows BK, et al. JAMA Cardiol. 2022;7:204-212.

Racial and ethnic inequities are increasingly being linked to health disparities. This study of more than 16,000 patients explored the association between race and ethnicity and blood pressure control. Findings suggest racial and ethnic inequities in treatment intensification may be associated with more than 20% of observed racial or ethnic disparities in blood pressure control.

How nursing homes’ worst offenses are hidden from the public.

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Gebeloff R, Thomas K, Silver-Greenberg J. New York Times. December 9, 2021.

Nursing homes harbor numerous challenges to patient safety and they should be transparently reported and acted upon to ensure improvement. This news investigation discusses a gap in the reporting and inspection of nursing home incidents that undermines the ability of the US nursing home rating system to inform consumer long term care facility choice.

Race as a social construct in psychiatry research and practice.

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Bryant BE, Jordan A, Clark US. JAMA Psych. 2022;79:93-94.

Research and medical practice are negatively affected by systemic and implicit bias. This commentary discusses this phenomenon in the mental health sector and suggests a role for researchers to reduce the inappropriate use of race in psychiatric practice while limiting its detrimental impact on care nationwide.

We Can’t Do This Alone! The Role That Patients, Family Members, and the General Public Play in Advancing Patient Safety.

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Patient Safety Movement Foundation. January 25, 2022.

Successful patient safety improvements engage individuals across the continuum of care and administrative processes, including patients as advocates for change. This webinar highlighted the role of the patient in influencing legislation designed to affect systems of care to ensure safe practice.

NPSD Data Spotlight, Patient Safety and COVID-19: A Qualitative Analysis of Concerns During the Public Health Emergency, 2021.

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Rockville, MD: Agency for Healthcare Research and Quality; November 2021. AHRQ Pub. No. 22-0005.

This analysis of reports submitted by Patient Safety Organizations during the early months of the COVID pandemic found that patients testing positive for COVID-19 or being investigated for carrying the virus was the most frequently reported patient safety concern (26.6%). In addition, patients and staff being exposed to individuals who had tested positive for COVID-19 was identified as a patient safety issue in 18.2% of the records analyzed.

To eliminate bias, some seek out doctors of their own race or ethnicity.

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Glicksman E. Washington Post. December 11, 2021.

A successful patient/physician relationship enables care that is specific for the individual, their unique concerns, and distinct lifestyles. This article discusses patient choice in physicians as a strategy to reduce the impact of implicit ethnic bias, while arguing that fundamental change will occur only by reducing racism through system change.

Burnout, engagement, and dental errors among U.S. dentists.

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Yansane A, Tokede O, Walji MF, et al. J Patient Saf. 2021;17:e1050-e1056.

Clinician burnout is a known threat to patient safety. This survey of a national sample of dentists found that approximately 1 in 10 respondents reported high levels of burnout and 50% of respondents reported a perceived dental error in the last 6 months. Efforts to minimize burnout among dentists may help improve patient safety.

Using failure mode and effects analysis to increase patient safety in cancer chemotherapy.

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Weber L, Schulze I, Jaehde U. Res Social Adm Pharm. 2022;18:3386-3393.

Chemotherapy administration errors can result in serious patient harm. Using failure mode and effects analysis (FMEA), researchers identified potential failures related to the medication process for intravenous chemotherapy. Common failures included incorrect patient information, non-standardized chemotherapy protocols, and problems related to supportive therapy.

Filling the gaps on the Institute for Safe Medication Practices (ISMP) Do Not Crush List for Immediate-release Products

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Uttaro E, Zhao F, Schweighardt A. Int J Pharm Compd. 2021;25(5):364-371.

Medication administration, particularly when it involves drug formulation manipulation, is a complex process. This study analyzed the products included on the Institute for Safe Medication Practices’ (ISMP) ‘Do Not Crush List’ and found that many presented no risk or low risk for crushing. The authors provide recommendations for clinicians to aid in clinical decision-making regarding crushing, such as suitable personal protective equipment and prompt administration.

ASK ME!-Routine measurement of patient experience with patient safety in ambulatory care: a mixed-mode survey

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Stahl K, Groene O. PLoS ONE. 2021;16:e0259252.

Patient safety in ambulatory care is an emerging focus of measurement and improvement efforts. This cross-sectional study including patients from 22 ambulatory care practices in Germany found that nearly 3% of respondents had experienced a patient safety event during the last 12 months. The authors discuss how different approaches to voluntary reporting can influence measurement of patient experience.

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