Skip to main content

All Content

Search Tips
Save
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Narrow Results By
PSNet Original Content
Additional Filters
1 - 20 of 144
Townsend T, Cerdá M, Bohnert AS, et al. Health Aff (Millwood). 2021;40:1766-1775.
Misuse of prescription opioids represents a serious patient safety issue. Using commercial claims from 2014 - 2018, researchers examined the association between the 2016 CDC guidelines to reduce unsafe opioid prescribing and opioid dispensing for patients with four common chronic pain diagnoses. Findings indicate that the release of the 2016 guidelines was associated with reductions in the percentage of patients receiving opioids, average dose prescribed, percentage receiving high-dose prescriptions, number of days supplied, and the percentage of patients receiving concurrent opioid/benzodiazepine prescriptions. The authors observe that questions remain about how clinicians are tailoring opioid reductions using a patient-centered approach.
Meyer AND, Giardina TD, Khawaja L, et al. Patient Educ Couns. 2021;104:2606-2615.
Diagnostic uncertainty can lead to misdiagnosis and delayed treatment. This article provides an overview of the literature on diagnosis-related uncertainty, where uncertainty occurs in the diagnostic process and outlines recommendations for managing diagnostic uncertainty.

Rockville, MD: Agency for Healthcare Research and Quality. Special Emphasis Notice. October 28, 2021 Publication No. NOT-HS-22-004.

Digital information tools are increasingly relied upon to assist in care communication and decision support, yet their safety hasn’t been fully examined. This announcement highlights AHRQ interest in funding research on the safe use of digital information solutions with a focus on program implementation, system design, and usability.
Schiff G, Shojania KG. BMJ Qual Saf. 2022;31:148-152.
This commentary discusses Dr. Lucian Leape’s new book and highlights the ongoing challenges to sustained quantifiable progress to improving patient safety, including misguided metrics, equipment design issues, persistence of fear and blame culture, burnout and shortages of nurses, primary care and other essential workers.
Rosenthal CM, Parker DM, Thompson LA. JAMA Pediatr. 2022;176:119-120.
The care of child abuse victims is affected by resource, racial and infrastructure challenges. This commentary describes how the systemic weaknesses catalyzed by poor data collection approaches contribute to misdiagnosis and suggests that successes be mined to minimize the proliferation of continued disparities in this patient population.

Bajaj K, de Roche A, Goffman D. Rockville, MD: Agency for Healthcare Research and Quality; September 2021. AHRQ Publication No. 20(21)-0040-6-EF.

Maternal safety is threatened by systemic biases, care complexities, and diagnostic issues. This issue brief explores the role of diagnostic error in maternal morbidity and mortality, the preventability of common problems such as maternal hemorrhage, and the importance of multidisciplinary efforts to realize improvement. The brief focuses on events occurring during childbirth and up to a week postpartum.
Waddell AE, Gratzer D. Can J Psychiatry. 2021:070674372110365.
Safety gaps in mental health care offers a limited view if focused primarily on patient suicide. This commentary calls for Canadian psychiatric professionals to examine the safety of their patients from a system perspective to develop a research and practice improvement strategy.

Rockville, MD: Agency for Healthcare Research and Quality; September 9, 2021. PA-21-267. 

This funding opportunity supports large research demonstration and implementation projects applying existing strategies to understand and reduce adverse events in ambulatory and long-term care settings. Projects focused on preventing harm in disadvantaged populations to improve equity are of particular interest. The funding cycle will be active through May 27, 2024.
Burrus S, Hall M, Tooley E, et al. Pediatrics. 2021;148:e2020030346.
Based on analysis of four years of data submitted to the Child Health Patient Safety Organization (CHILDPSO), researchers sought to identify types of serious safety events and contributing factors. Three main groups of serious safety events were identified: patient care management, procedural errors, and product or device errors. Contributing factors included lack of situational awareness, process failures, and failure to communicate effectively.
Fenton SH, Giannangelo KL, Stanfill MH. J Am Med Inform Assoc. 2021;28:2346-2353.
The World Health Organization (WHO) released the International Classification of Diseases, 11th Revision (ICD-11) in 2018. In addition to the medical entities such as disease and injury, it contains a second component, the ICD-11 Mortality and Morbidity Statistics (MMS) linearization. The authors evaluated whether the ICD-11 MMS is appropriate for use in patient safety and quality or if a USA-specific clinical modification is necessary. 
Korenstein D, Harris RP, Elshaug AG, et al. J Gen Intern Med. 2021;36:2105-2110.
Provider and patient underestimation of harms of tests and treatments may lead to over treatment. This article presents seven domains of harm of tests and treatment which warrant comprehensive research: (1) physical impairment, (2) psychological distress, (3) social disruption, (4) disruption in connection to healthcare, (5) labeling, (6) financial impact, and (7) treatment burden. Research is especially important in vulnerable patient populations.
Keister LA, Stecher C, Aronson B, et al. BMC Public Health. 2021;21:1518.
Constrained diagnostic situations in the emergency department (ED), such as crowding, can impact safe care. Based on multiple years of electronic health record data from one ED at a large U.S. hospital, researchers found that providers were significantly less likely to prescribe opioids during constrained diagnostic situations and less likely to prescribe opioids to high-risk patients or racial/ethnic minorities.

National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2021.

Misdiagnosis of severe cardiovascular events is a primary concern to the diagnostic safety community due to its prevalence and potential for harm. This report summarizes a session discussion on the existing evidence base on improving diagnosis for these conditions and explore opportunities for improvement.
Petrosoniak A, Fan M, Hicks CM, et al. BMJ Qual Saf. 2021;30:739-746.
Trauma resuscitation is a complex, specialized process with a high risk for errors. Researchers analyzed videotapes of in situ simulations to evaluate latent safety events occurring during trauma resuscitation. Themes influencing latent safety events related to physical workspace, mental model formation, equipment, unclear accountability, demands exceeding individuals’ capacity, and task-specific issues.
Pinheiro LC, Reshetnyak E, Safford MM, et al. Med Care. 2021;59:901-906.
Prior research has found that racial/ethnic minorities may be at higher risk for adverse patient safety outcomes. This study evaluated racial disparities in self-reported adverse events based on cross-sectional survey data collected as part of a national, prospective cohort evaluating stroke mortality. Findings show that Black participants were significantly more likely to report a preventable adverse event attributable to poor care coordination (e.g., drug-drug interaction, emergency department visitor, or hospitalization) compared to White participants.
Marziliano A, Burns E, Chauhan L, et al. J Gerontol A Biol Sci Med Sci. 2022;77:e124-e132.
Many COVID-19 patients present with atypical symptoms, such as delirium, smell and taste dysfunction, or cardiovascular features. Based on inpatient electronic health record data between March 1 and April 20 of 2020, this cohort study examined the frequency of atypical presentation of COVID-19 among older adults. Analyses suggest that atypical presentation was often characterized by functional decline or altered mental status.
Miller-Kleinhenz JM, Collin LJ, Seidel R, et al. J Am Coll Radiol. 2021;18:1384-1393.
Delayed diagnosis and treatment of breast cancer can lead to poor outcomes. Based on multi-year data from one health system, the authors of this cohort study found that black women with screen-detected breast cancers were more likely than white women to experience diagnostic delays, including delays in diagnostic evaluation and biopsy. The delay in diagnosis was also associated with an increase in breast cancer mortality.
Alexander RG, Yazdanie F, Waite S, et al. Front Neurosci. 2021;15:629469.
Incorrect interpretation of radiologic images can result in delayed diagnosis or unneeded additional tests and treatment. This commentary describes the visual illusions radiologists use in detecting and categorizing abnormalities, and recommends further research into the ways visual illusions are used in order to improve diagnostic safety.
Galanter W, Eguale T, Gellad WF, et al. JAMA Netw Open. 2021;4:e2117038.
One element of conservative prescribing is minimizing the number of medications prescribed. This study compared the number of unique, newly prescribed medications (personal formularies) of primary care physicians across four health systems. Results indicated wide variability in the number of unique medications at the physician and institution levels. Further exploration of personal formularies and core drugs may illuminate opportunities for safer and more appropriate prescribing.

Houston, TX:  Baylor College of Medicine.

This Center represents a partnership with the Veterans Affairs Health Services Research & Development Center of Innovation to enhance researchers' skills through active participation in diagnostic safety research and policy development. The goals of the program include a focus on behavioral health interventions and measurement.