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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 28 Results
Mackenhauer J, Winsløv J-H, Holmskov J, et al. Crisis. 2021;43:307-314.
Prior research has found that patients who die by suicide often had recent contact with the healthcare setting. Based on a multi-year chart review at one institution, the authors concluded that suicide risk assessment and documentation in the heath record to be insufficient. The authors outline quality improvement recommendations focused on improving documentation, suicide assessment and intervention training, and improving communications with families, caregivers, and other health care providers.
Ash JS, Corby S, Mohan V, et al. J Amer Med Inform Assoc. 2021;28:294-302.
The use of medical scribes for electronic health record (EHR) documentation is one strategy to shift the burden of documentation away from clinicians. Using interviews and direct observations, the authors explored the effects of scribes on patient safety. Participants did not perceive significant patient safety risks with scribes and highlighted the positive effects scribes have on documentation efficiency, quality, and safety.
Meyer AND, Upadhyay DK, Collins CA, et al. Jt Comm J Qual Patient Saf. 2021;47:120-126.
Efforts to reduce diagnostic error should include educational strategies for improving diagnosis. This article describes the development of a learning health system around diagnostic safety at one large, integrated health care system. The program identified missed opportunities in diagnosis based on clinician reports, patient complaints, and risk management, and used trained facilitators to provide feedback to clinicians about these missed opportunities as learning opportunities. Both facilitators and recipients found the program to be useful and believed it would improve future diagnostic safety. 
Duhn L, Godfrey C, Medves J. Health Expect. 2020;23:979-991.
This scoping review characterized the evidence base on patients’ attitudes and behaviors concerning their engagement in ensuring the safety of their care. The review found increasing interest in patient and family engagement in safety and identified several research gaps, such as a need to better understand patients’ attitudes across the continuum of care, the role of family members, and engagement in primary care safety practices.
Ingrassia PL, Capogna G, Diaz-Navarro C, et al. Adv Simul (Lond). 2020;5:13.
The authors of this article outline ten recommendations for safely reopening simulation facilities for clinical training in the post-lockdown phase of the COVID-19 crisis. The recommendations are based on national guidance and regulations, as well as international public health recommendations. Future reopening activities should focus on safety as well as flexibility principles, taking different contexts and facility characteristics into account.
Kumar PR, Nash DB. Am J Med Qual. 2020;36:185-196.
The outpatient setting is receiving increased attention as a research focus in patient safety. This bibliography provides an annotated list of articles summarizing safety improvement efforts in the ambulatory setting since 2016. Topics explored include safety culture, measurement, team training, test result management, incident reporting, and diagnostic error.
Houghton C, Meskell P, Delaney H, et al. Cochrane Database Syst Rev. 2020;4:CD013582.
To support the needs of healthcare workers during the COVID-19 pandemic, this rapid evidence review of qualitative research studies sought to identify barriers and facilitators to healthcare workers adherence to infection prevention and control guidelines for respiratory infectious diseases. The authors included 20 studies in their analysis; these studies explored the views and experiences of nurses, doctors and other healthcare workers working in hospitals, primary care, and community care settings dealing with infectious diseases such as SARS, H1N1, MERS, TB, or seasonal influenza. Identified barriers included local guidelines that were lengthy, ambiguous or not reflective of national or international continuously changing guidelines, lack of support from management to adhere to guidelines, and lack of high-quality personal protective equipment (PPE). Facilitators to guideline adherence included clear communication and training about the infection and use of PPE, sufficient space to isolate patients, workplace safety culture, and perceived value of adhering to infection prevention and control guidelines.
Suda KJ, Zhou J, Rowan SA, et al. Am J Prev Med. 2020;58:473-486.
National guidelines published in 2016 recommend prescribing low-dose opioids for short durations when necessary, including in dentistry practices. This cross-sectional analysis of over 500,000 commercial dental patients over a five-year period (2011-2015) examined prescribing practices prior to the recommendations and found that 29% of prescribed opioids exceeded the recommended dose for management of acute pain and half (53%) exceeded the recommended days’ supply. The authors emphasize the importance of evidence-based interventions tailored to dentistry to curtail excessive opioid prescribing.
Miller W, Asselbergs M, Bank J, et al. Healthc Q. 2020;22.
This article describes learning collaboratives conducted by the Canadian Patient Safety Institute and Canadian Home Care Association aimed at increasing capacity and capability to improve healthcare quality and mitigate and prevent harm from homecare safety incidents such as falls.
Ding JM, Ehrenfeld JM, Edmiston EK, et al. Jt Comm J Qual Patient Saf. 2020;46:37-43.
This article describes the development and implementation of a multifaceted, community-engaged program to improving the quality of healthcare for transgender and gender nonconforming patients. The program – which includes transgender patient advocacy, a community advisory board, and a transgender health clinic – serves as a model that can be adopted by other health care systems.
Bundy DG, Singh H, Stein RE, et al. Clin Trials. 2019;16:154-164.
Diagnostic errors in pediatric primary care are common and represent an ongoing patient safety challenge. In this stepped-wedge, cluster-randomized trial, researchers were able to successfully recruit a diverse group of pediatric primary care practices to participate in virtual quality improvement collaboratives designed to reduce diagnostic error.
Darnall BD, Ziadni MS, Stieg RL, et al. JAMA Intern Med. 2018;178:707-708.
This prospective cohort study found that many outpatients treated at a chronic pain clinic were willing to voluntarily taper opioid medications. Although nearly 40% of patients dropped out of the study, those that remained significantly reduced their opioid dosing. The authors suggest that offering a voluntary gradual opioid taper to patients with chronic pain may reduce their opioid dose.
Parand A, Garfield S, Vincent C, et al. PLoS One. 2016;11:e0167204.
Medication administration errors have been studied primarily in the hospital environment. Less is known about the types of errors that may occur in the home setting and the role caregivers play in this context. This narrative systematic review found caregiver medication administration error rates ranging from 1.9% to 33% of all medications administered, highlighting a potential threat to patient safety.
Berry JC, Davis JT, Bartman T, et al. J Patient Saf. 2020;16:130-136.
A culture of safety is a fundamental component of patient safety. Several validated survey tools are available to measure hospital safety and teamwork climates, including the AHRQ Surveys on Patient Safety Culture and the Safety Attitudes Questionnaire (SAQ). Improvements in SAQ scores have been previously linked to reductions in specific safety outcomes, such as maternal and fetal adverse events in an obstetric ward. This study explored SAQ results and outcomes across all inpatient and outpatient care units in a large academic health system. Beginning in 2009, Nationwide Children's Hospital in Ohio introduced a comprehensive patient safety and high reliability program that included numerous quality improvement activities and extensive training in error prevention for each of their approximately 10,000 employees. Over the course of 4 years, SAQ scores improved while all-hospital harm, serious safety events, and severity-adjusted hospital mortality all decreased significantly. A prior WebM&M interview with J. Bryan Sexton, the primary author of the SAQ instrument, discussed the relationship between culture and safety.
Shah R, Blustein L, Kuffner E, et al. J Pediatr. 2014;164:596-601.e1.
This observational study of community pharmacies found that liquid medication dosing instructions for pediatric patients did not consistently reflect recommended best practices. This finding underscores the need to translate safety research into clinical practice.
Ryan R, Santesso N, Lowe D, et al. Cochrane Database Syst Rev. 2014:CD007768.
This review describes how researchers identified and analyzed systematic reviews on interventions to augment safe medication use. The authors provide an overview of safety improvement strategies, such as reminders and financial incentives. Medication self-management programs generally enhanced medication safety and health outcomes, but more research is needed for clinically complex populations and technology-enabled strategies.
Schnipper JL, Liang CL, Hamann C, et al. J Am Med Inform Assoc. 2011;18:309-13.
Efforts to prevent medication-related adverse events after hospital discharge have largely focused on medication reconciliation at the time of discharge. This study reports on the early experience with a medication reconciliation tool for use by primary care physicians after discharge. Although initial uptake was low, the study reports on many lessons learned through initial implementation.