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.

Search All Content

Clear all filter(s)

Clear all filter(s)

Displaying 1 - 20 of 238 Results

Patients' experiences and perspectives of patient-reported outcome measures in clinical care: a systematic review and qualitative meta-synthesis.

Save to Library

Carfora L, Foley CM, Hagi-Diakou P, et al. PLoS ONE. 2022;17:e0267030.

Patients are frequently asked to complete patient-reported outcome measures (PROM), or standardized questionnaires, to assess general quality of life, screen for specific conditions or risk factors, and perspectives on their health. This review identified 14 studies related to patient perspectives regarding PROMs. Three themes emerged: patient preferences regarding PROMs, patient perceived benefits, and barriers to patient engagement with PROMs.

Engaging patients in the use of real-time electronic clinical data to improve the safety and reliability of their own care.

Save to Library

Schnock KO, Roulier S, Butler J, et al. J Patient Saf. 2022;18:e407-e413.

Patient safety dashboards are used to communicate real-time patient data to appropriately augment care. This study found that higher usage of an electronic patient safety dashboard resulted in lower 30-day readmission rates among patients discharged from adult medicine units compared to lower usage groups.

Is it time for the mental health field to consider unplanned discharge a key metric of patient safety?

Save to Library

Riblet NB, Gottlieb DJ, Watts BV, et al. J Nerv Ment Dis. 2022;210:227-230.

Unplanned discharges (also referred to as leaving against medical advice) can lead to adverse patient outcomes. This study compared unplanned discharges across Veterans Health Affairs (VHA) acute inpatient and residential mental health treatment settings over a ten-year period and found that unplanned discharges are significantly higher in mental health settings. The authors recommend that unplanned discharges be measured to assess patient safety in mental health.

Identifying patients whose symptoms are underrecognized during treatment with breast radiotherapy.

Save to Library

Jagsi R, Griffith KA, Vicini F, et al for the Michigan Radiation Oncology Quality Consortium. JAMA Oncol. Epub 2022 Apr 21.

Concordance of patient-reported symptoms and provider-documented symptoms is necessary for appropriate patient care and has clinical implications for research. This study compared patient-reported symptoms (pain, pruritus, edema, and fatigue) following radiotherapy for breast cancer with provider assessments. Underrecognition of at least one symptom occurred in more than 50% of patients. Underrecognition was more common in Black patients and those seen by male physicians. The authors suggest that interventions to improve communication between providers and patients may not only improve outcomes but also reduce racial disparities.

Effect of the surgical safety checklist on provider and patient outcomes: a systematic review.

Save to Library

Armstrong BA, Dutescu IA, Nemoy L, et al. BMJ Qual Saf. 2022;31:463-478.

Despite widespread use of surgical safety checklists (SSC), its success in improving patient outcomes remains inconsistent, potentially due to variations in implementation and completion methods. This systematic review sought to identify how many studies describe the ways in which the SSC was implemented and completed, and the impact on provider outcomes, patient outcomes, and moderating factors. A clearer positive relationship was seen for provider outcomes (e.g., communication) than for patient outcomes (e.g., mortality).

Factors associated with workplace violence among healthcare workers in an academic medical center.

Save to Library

Otachi JK, Robertson H, Okoli CTC. Perspect Psychiatr Care. 2022;58:2383-2393.

Workplace violence in healthcare settings can jeopardize the safety of both patients and healthcare workers. This study found that over half of healthcare workers at one large academic medical center in the United States reported witnessing or experiencing workplace violence. Witnessing or experiencing workplace violence was most common in psychiatric settings and in the emergency department.

The effect of clinician feedback interventions on opioid prescribing.

Save to Library

Navathe AS, Liao JM, Yan XS, et al. Health Aff (Millwood). 2022;41:424-433.

Opioid overdose and misuse continues to be a major public health concern with numerous policy- and organization-level approaches to encourage appropriate clinician prescribing. A northern California health system studied the effects of three interventions (individual audit feedback, peer comparison, both combined) as compared to usual care at several emergency department and urgent care sites. Peer comparison and the combined interventions resulted in a significant decrease in pills per prescription.

The justification for strike action in healthcare: a systematic critical interpretive synthesis.

Save to Library

Essex R, Weldon SM. Nurs Ethics. 2022;29:1152-1173.

Appropriate staffing levels have been shown to impact patient safety and patient outcomes. This review of literature on healthcare worker strikes explores potential negative impacts, such as compromised patient safety due to decreased staffing levels, and justifications, such as long-term benefits.

Diagnostic Centers of Excellence: Partnerships to Improve Diagnostic Safety and Quality (R18).

Save to Library

Rockville, MD: Agency for Healthcare Research and Quality; April 7, 2022. RFA-HS-22-008.

Improving diagnosis and reducing diagnostic errors are patient safety priorities. This announcement supports the development of Diagnostic Centers of Excellence focused on improving frontline diagnostician support and improving diagnostic systems (i.e., improving diagnostic precision through consensus, improving “truth” or diagnostic reference standards). The application process is now closed.

Occurrence of no-harm incidents and adverse events in hospitalized patients with ischemic stroke or TIA: a cohort study using trigger tool methodology.

Save to Library

Nowak B, Schwendimann R, Lyrer P, et al. Int J Environ Res Public Health. 2022;19:2796.

Diagnostic error and misdiagnosis of stroke patients can lead to preventable adverse events, such as treatment delays and adverse outcomes. Researchers at a Swiss hospital retrospective reviewed patients admitted for transient ischemic attack (TIA) or ischemic stroke and found that a trigger tool could accurately identify preventable events among patients with adverse events and no-harm incidents. The most common preventable events were medication events, pressure injuries, and healthcare-associated infections.

Relationship between physician burnout and the quality and cost of care for Medicare beneficiaries is complex.

Save to Library

Casalino LP, Li J, Peterson LE, et al. Health Aff (Millwood). 2022;41:549-556.

Physician burnout has been associated with higher rates of self-reported medical errors and increased costs related to physician turnover. This analysis linked survey data from family physicians to Medicare claims to explore any association of burnout with four objective measures of care outcomes (ambulatory care-sensitive admissions, ambulatory care-sensitive emergency department visits, readmissions, or costs). There was no consistent, statistically significant relationship between burnout and the four measures of care outcomes and further research on this relationship is warranted.

Effectiveness and safety of pulse oximetry in remote patient monitoring of patients with COVID-19: a systematic review.

Save to Library

Alboksmaty A, Beaney T, Elkin S, et al. Lancet Digit Health. 2022;4:e279-e289.

The COVID-19 pandemic led to a rapid transition of healthcare from in-person to remote and virtual care. This review assessed the safety and effectiveness of pulse oximetry in remote patient monitoring (RPM) of patients at home with COVID-19. Results show RPM was safe for patients in identifying risk of deterioration. However, it was not evident whether remote pulse oximetry was more effective than other virtual methods, such as virtual visits, monitoring consultations, or online or paper diaries.

Workarounds in electronic health record systems and the revised Sociotechnical Electronic Health Record Workaround Analysis Framework: scoping review.

Save to Library

Blijleven V, Hoxha F, Jaspers MWM. J Med Internet Res. 2022;24:e33046.

Electronic health record (EHR) workarounds arise when users bypass safety features to increase efficiency. This scoping review aimed to validate, refine, and enrich the Sociotechnical EHR Workaround Analysis (SEWA) framework. Multidisciplinary teams (e.g. leadership, providers, EHR developers) can now use the refined SEWA framework to identify, analyze and resolve unsafe workarounds, leading to improved quality and efficiency of care.

Inviting patients to identify diagnostic concerns through structured evaluation of their online visit notes.

Save to Library

Giardina TD, Choi DT, Upadhyay DK, et al. J Am Med Inform Assoc. 2022;29:1091-1100.

Most patients can now access their provider visit notes via online portals and many have reported mistakes such as diagnostic errors or missed allergies. This study asked patients who may be “at-risk” for diagnostic error about perceived concerns in their visit notes. Patients were more likely to report having concerns if they did not trust their provider and did not have a good feeling about the visit. Soliciting patient concerns may be one way to improve transparency regarding diagnostic errors and trust in providers.

Family support role in hospital rapid response teams: a scoping review.

Save to Library

Howlett O, Gleeson R, Jackson L, et al. JBI Evid Synth. 2022;20:2001-2024.

Rapid response teams are designed to provide emergency medical support to deteriorating hospitalized patients. This review examines the role of a family support person (FSP) as part of the rapid response team. The FSP supported the family during the resuscitation in numerous ways, such as explaining jargon and medical procedures and attending to the practical needs of the family.

Psychological intervention to improve communication and patient safety in obstetrics: examination of the health action process approach.

Save to Library

Derksen C, Kötting L, Keller FM, et al. Front Psychol. 2022;13:771626.

Effective communication and teamwork are fundamental to ensure safe patient care. Building on their earlier systematic review of communication interventions in obstetric care, researchers developed and implemented a training, TeamBaby, to improve communication at two obstetric hospitals. While results did not show a change in communication behavior, perceived patient safety did improve. Additional resources are available in the curated library on maternal safety.

To what extent are patients involved in researching safety in acute mental healthcare?

Save to Library

Brierley-Jones L, Ramsey L, Canvin K, et al. Res Involv Engagem. 2022;8:8.

Patient engagement in safety efforts is encouraged, but patients are less often included as active participants in designing patient safety interventions. This review identified 52 studies that included mental health patients in the design, delivery, implementation, and/or evaluation of patient safety research. The authors argue that increased inclusion of patients in safety research may lead to development of higher quality safety interventions.

Safety in fragile, conflict-affected, and vulnerable settings: An evidence scanning approach for identifying patient safety interventions.

Save to Library

O’Brien N, Shaw A, Flott K, et al. J Glob Health. 2022;12:04018.

Improving patient safety is a global goal. This literature review explored patient safety interventions focused on people living in fragile, conflict-affected, and vulnerable settings. Studies were generally from lower and lower-middle income countries and focused primarily on strengthening infection prevention and control; however, there is a call for more attention on providing patient safety training to healthcare workers, introducing risk management tools, and reducing preventable harm during care delivery.

Effects of state opioid prescribing laws on use of opioid and other pain treatments among commercially insured U.S. adults.

Save to Library

McGinty EE, Bicket MC, Seewald NJ, et al. Ann Intern Med. 2022;175:617-627.

Prior research has found that unsafe opioid prescribing practices are common. This retrospective study explored the association between state opioid prescribing laws and trends in opioid and nonopioid pain treatment among commercially insured adults in the United States. Findings suggest that these laws were not associated with statistically significant changes in prescribing outcomes, but the authors note that some of these estimates were imprecise and may not be generalizable to non-commercially insured populations.

Diagnostic error in pediatrics: a narrative review.

Save to Library

Marshall TL, Rinke ML, Olson APJ, et al. Pediatrics. 2022;149:e2020045948D.

Reducing diagnostic errors in pediatric care remains a critical area of research and quality improvement. This narrative review presents the incidence and epidemiology of pediatric diagnostic error and strategies for additional innovative research to develop effective interventions to reduce these errors.

The PSNet Collection: All Content

Search All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

The PSNet Collection: All Content

Search All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site