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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 41 - 60 of 16714 Results
Schefft M, Noda A, Godbout E. Curr Treat Options Pediatr. 2021;7:138-151.
Overuse of medical care represents a significant patient safety challenge. This review discusses the impacts of healthcare overuse and unnecessary care on patient safety, including contributions to avoidable adverse events, increasing risks for healthcare-acquired infections, and adverse psychological outcomes.
McGaughey J, Fergusson DA, Van Bogaert P, et al. Cochrane Database Syst Rev. 2021;11:CD005529.
Rapid response systems (RRS) and early warning systems (EWS) are designed to detect patient deterioration and prevent cardiac arrest, transfer to the intensive care unit, or death. This review updates the authors’ review published in 2007. Eleven studies representing patients in 282 hospitals were reviewed to determine the effect of RRS or EWS on patient outcomes.
Kemp T, Butler‐Henderson K, Allen P, et al. Health Info Libr J. 2021;38:248-258.
This review focused on the impact of the Health Information Management (HIM) profession on patient safety as it relates to health information documentation. Key themes identified were data quality, information governance, corporate governance, skills, and knowledge required for HIM professionals.
Haque H, Alrowily A, Jalal Z, et al. Int J Clin Pharm. 2021;43:1693-1704.
While direct oral anticoagulants (DOAC) are considered safer than warfarin, DOAC-related medication errors still occur. This study assesses the frequency, type, and potential causality of DOAC-related medication errors and the nature of clinical pharmacist intervention. Active, rather than latent, failures contributed to most errors.
Gibson BA, McKinnon E, Bentley RC, et al. Arch Pathol Lab Med. 2022;146:886-893.
A shared understanding of terminology is critical to providing appropriate treatment and care. This study assessed pathologist and clinician agreement of commonly-used phrases used to describe diagnostic uncertainty in surgical pathology reports. Phrases with the strongest agreement in meaning were “diagnostic of” and “consistent with”. “Suspicious for” and “compatible with” had the weakest agreement. Standardized diagnostic terms may improve communication.
Draus C, Mianecki TB, Musgrove H, et al. J Nurs Care Qual. 2022;37:110-116.
“Second victims” are healthcare providers who experience negative feelings in their personal or professional lives after being involved in unanticipated adverse patient events. One hundred and fifty-nine nurses at one American hospital reported being a second victim and experiencing psychological and/or physical distress following the incident.
Brown B, Bermingham S, Vermeulen M, et al. BMJ Open Qual. 2021;10:e001593.
Despite evidence of the benefits of the World Health Organization’s surgical safety checklist, implementation and sustainability are inconsistent in many hospitals. Using five cycles of Plan-Do-Study-Act, a hospital in Adelaide, South Australia, was able to increase use of the checklist from 3.5% to 63%. Staff reported that they felt the new checklist process improved patient safety and was easily incorporated into their workflow.
Anand TV, Wallace BK, Chase HS. BMC Geriatr. 2021;21:648.
Older adults, particularly those taking more than one medication, are at increased risk of adverse drug events (ADE). In this study of 6,545 older adult patients who were prescribed at least 3 medications, multidrug interactions (MDI) were identified in 1.3% of medication lists. Psychotropic medications were the most commonly involved medication class; the most common serious ADE were serotonin syndrome, seizures, prolonged QT interval, and bleeding.
London, UK: Parliamentary and Health Service Ombudsman.
The National Health Service broadly reports the results of system-level analyses and investigations into trust-specific failures. This publication series provides information about complaints submitted to trusts to track complaints received and responded to, identify common themes, and uncover recurring problems in an effort to enable organizations to improve processes for managing complaints.
Shen L, Levie A, Singh H, et al. Jt Comm J Qual Patient Saf. 2022;48:71-80.
The COVID-19 pandemic has exacerbated existing challenges associated with diagnostic error. This study used natural language processing to identify and categorize diagnostic errors occurring during the pandemic. The study compared a review of all patient safety reports explicitly mentioning COVID-19, and using natural language processing, identified additional safety reports involving COVID-19 diagnostic errors and delays. This innovative approach may be useful for organizations wanting to identify emerging risks, including safety concerns related to COVID-19.

Rockville, MD: Agency for Healthcare Research and Quality; December 2021. AHRQ Publication No. 22-0009.

In consultation with AHRQ, the U.S. Department of Health and Human Services delivered a final report on effective strategies to improve patient safety and reduce medical errors to Congress. Required by the Patient Safety Act of 2005, the report was made available for public review and comment, and review by the National Academy of Medicine. It outlined several strategies to accelerate progress in improving patient safety, including using analytic approaches in patient safety research, measurement, and practice improvement to monitor risk; implementing evidence-based practices in real-world settings through clinically useful tools and infrastructure; encouraging the development of learning health systems that integrate continuous learning and improvement in day-to-day operations; and encouraging the use of patient safety strategies outlined in the National Action Plan by the National Steering Committee for Patient Safety.
Ciapponi A, Fernandez Nievas SE, Seijo M, et al. Cochrane Database Syst Rev. 2021;11:CD009985.
Medication errors can lead to harm in hospitalized patients including increased length of stay, lower quality of life, increased morbidity, and even death. This review of 65 studies and 110,875 patients examined interventions (primarily medication reconciliation) and their effect on reducing adverse drug events. Findings revealed mostly low to moderate certainty about the effectiveness of medication reconciliation and low certainty on other interventions, emphasizing the importance of research that has greater power and is methodologically sound.
Centola D, Guilbeault D, Sarkar U, et al. Nature Commun. 2021;12:6585.
Race and gender bias in healthcare remains a public health problem. Study participants were assigned to a control (i.e., independent reflection) or intervention (i.e., “egalitarian” information exchange network) group and asked to provide diagnostic and treatment recommendations for standardized patients (a white man or a black woman). Participants in the intervention group were more likely to recommend appropriate care and showed no bias in final recommendations. The authors note that these findings indicate that clinician network interventions might be useful in healthcare settings to reduce disparities in patient treatment.

ISMP Medication Safety Alert! Acute care edition. December 2, 2021;(24)1-4.

Insulin is a high-alert medication that requires extra attention to safely manage blood sugar levels in chronic or acutely ill patients. This alert highlights look-alike/sound-alike packaging, delayed medication reconciliation, and dietary monitoring gaps as threats to safe insulin administration in emergencies. Recommendations for improvement are provided for both general in-hospital, and post-discharge care.

Ruskin KJ, ed. Curr Opin Anaesthesiol. 2021;34(6):720-765

Anesthesia services are high risk despite progress made in the specialty to improve its safety. This special section covers issues that affect anesthesia safety such as critical incident debriefing, human factors, and educational strategies.

National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American Society of Health-System Pharmacists. December 6, 2021. 

Vaccine missteps are known to occur during flu and COVID-19 inoculation efforts. This announcement raises awareness of misadministration of COVID vaccines associated with patient age. It highlights storage protocols as one approach to minimize mistakes. This alert is part of a national program to distribute learnings from report analysis to improve medication safety.

Rockville MD, Agency for Healthcare Quality and Research. December 7, 2021.

The TeamSTEPPS program is an established approach for improving teamwork and communication in health care. This announcement calls for feedback from healthcare teams and team members on how to update the current TeamSTEPPS training curriculum. 
Wallis KA, Elley CR, Moyes SA, et al. BJGP Open. 2022;6:BJGPO.2021.0129.
Common high-risk medications such as antiplatelets and non-steroidal anti-inflammatory drugs (NSAIDs) have the potential to cause serious patient harm. This randomized trial examined the usefulness of an existing intervention to support safer prescribing in general practice to improve safe high-risk prescribing.
Thomas AD, Pandit C, Krevat S. J Patient Saf. 2021;17:e1605-e1608.
Building on prior research, this study identified racial differences in voluntarily reported near-miss events. Compared to white patients, black patients had fewer reported events but were more likely to experience near-miss events related to laboratory/specimen handling, blood bank, and safety/security.