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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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Curated Libraries
September 13, 2021
Ensuring maternal safety is a patient safety priority. This library reflects a curated selection of PSNet content focused on improving maternal safety. Included resources explore strategies with the potential to improve maternal care delivery and outcomes, such as high reliability, care standardization,teamwork, unit-based safety initiatives, and...
Kasick RT, Melvin JE, Perera ST, et al. Diagnosis (Berl). 2021;8:209-217.
Diagnostic errors can result in increased length of stay and unplanned hospital readmissions. To reduce readmissions, this hospital implemented a diagnostic time-out to increase the frequency of documented differential diagnosis in pediatric patients admitted with abdominal pain. Results showed marginal improvement in quality of differential diagnosis.
Hensgens RL, El Moumni M, IJpma FFA, et al. Eur J Trauma Emerg Surg. 2020;46:1367-1374.
Missed injuries and delayed diagnoses are an ongoing problem in trauma care. This cohort study conducted at a large trauma center found that inter-hospital transfer of severely injured patients increases the risk of delayed detection of injuries. For half of these patients, the new diagnoses led to a change in treatment course. These findings highlight the importance of clinician vigilance when assessing trauma patients.
Auerbach AD, O'Leary KJ, Greysen SR, et al. J Hosp Med. 2020;15:483-488.
Based on a survey of hospital medicine groups at academic medical centers in the United States (conducted April 2020), the authors of this study characterized inpatient adaptations to care for non-ICU COVID-19 patients. Sites reported rapid expansion of respiratory isolation units (RIUs – dedicated units for patients with known or suspected COVID-19), an emphasis on telemedicine for patient evaluation, and implementation of approaches to minimize room entry. In addition, nearly half of responding sites reported diagnostic errors involving COVID-19 (missing non-COVID-19 diagnoses among infected patients and missing COVID-19 diagnoses in patients admitted for other reasons).

American College of Radiology. March 11, 2020.

As COVID-19 spreads globally, there is growing interest in methods for rapid diagnosis and the risk of diagnostic error. Delayed diagnosis of COVID-19 may lead to worse patient outcomes and increased exposure of healthy individuals to the novel coronavirus. Two early studies suggested that chest CT may have a sensitivity as high as 97%. However, higher quality studies have shown that the sensitivity of chest CT is only 67-93% among patients with viral pneumonia and imaging features must be interpreted with caution when the prevalence of SARS-CoV-2 infection is low. Based on the risks of misdiagnosis and viral transmission, the American College of Radiology recommends that CT should not be used to screen for or as a first-line test to diagnose COVID-19. CT should be reserved for hospitalized, symptomatic patients with specific clinical indications.  
Gill S, Mills PD, Watts BV, et al. J Patient Saf. 2021;17:e898-e903.
This retrospective cohort study used root cause analysis (RCA) to examine safety reports from emergency departments at Veterans Health Administration hospitals over a two-year period. Of the 144 cases identified, the majority involved delays in care (26%), elopements (15%), suicide attempts and deaths (10%), inappropriate discharges (10%) and errors following procedures (10%). RCA revealed that primary contributory factors leading to adverse events were knowledge/educational deficits (11%) and policies/procedures that were either inadequate (11%) or lacking standardization (10%).
Pallok K, De Maio F, Ansell DA. N Engl J Med. 2019;380:1489-1493.
This editorial discusses how structural racism contributes to health inequities between blacks and whites in the United States, with an emphasis on cancer care. The authors propose three strategies for addressing structural racism in healthcare: (1) clinicians can make the invisible visible by examining disparities in their practices and exploring disparities in patient-level quality measures; (2) health care organizations can engage the community in an effort to change the accepted explanatory narrative, from one about biology or behavior to a story of a pathological social system that can be improved, and; (3) institutions can make systemic changes to eliminate structural racism by engaging in quality improvement efforts, educating healthcare workers, updating technical skills, and using patient navigators to connect patients to necessary services.