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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 32 Results
Frakt A. New York Times. August 26, 2019.
The slow adoption of improvement innovations is a persistent challenge to high-quality and safe patient care. This newspaper article raises concerns about how common treatments are recommended despite insufficient evidence regarding their effectiveness and provides examples of how this problem can result in harm, such as the previous physician belief that opioids were not addictive. Reassessment of science can improve safety and reduce the unintended consequences of ineffective treatments.
Shen C, Nguyen M, Gregor A, et al. JAMA Ophthalmol. 2019;137:690-692.
This study entered 42 validated clinical vignettes for eye diseases into an online symptom checker. As with prior studies, the performance of the online symptom checker in producing the correct diagnosis was suboptimal. The authors suggest that current performance of symptom checkers is not sufficient for timely and accurate diagnosis of ophthalmologic conditions.
Silver Spring, MD: US Food and Drug Administration; April 9, 2019.
Efforts to address the opioid epidemic range from regulation to changes in pain management. This safety announcement raises awareness of potential harms associated with rapidly decreasing the dose of or discontinuing opioids for patients who may be physically dependent on the medication. It also announces a requirement regarding changes to prescribing information for opioids to provide expanded guidance on how to safely taper doses. Health care providers should discuss tapering plans with patients and provide ongoing monitoring and support.
Schulte F; Fry E.
Despite years of investment and government support, electronic health records (EHR) continue to face challenges as a patient safety strategy. This news article outlines the unintended consequences of EHR implementation, including patient harm linked to software glitches and user errors, fraudulent behavior (upcoding), interoperability problems, clinician burnout due to poorly designed digital health records, and lack of industry transparency.
Dickson EJ. Rolling Stone. March 9, 2019.
Unintended consequences of restrictions enacted to combat the opioid crisis are a concern for patients and prescribers. This magazine article reports on an effort to raise awareness of the potential for patient harm due to lack of legitimate access to opioids for chronic pain as a result of the 2016 CDC opioid prescribing guidelines.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; November 14, 2018.
This safety announcement raises awareness of pump failures, dosing errors, and other potential safety issues associated with implanted pumps. Recommendations to enhance safety include review of medication labeling to select appropriate medicines and concentrations as well as open discussions with patients about risks associated with pump and medication options.
Gawande A. New Yorker. November 12, 2018.
In this magazine article, Atul Gawande describes a range of frustrations physicians experience as digitization becomes more widespread in health care. He elaborates upon several elements of electronic health record use that can degrade care processes and create conditions for errors, such as burnout, lack of patient-centeredness, and alert fatigue.

Landro L. Wall Street Journal. August. 8, 2016.

First-year residents may be reluctant to ask for assistance due to factors such as peer pressure to demonstrate competency. This newspaper article reports on one hospital's strategy to enhance communication among residents and attendings, which encourages residents to ask questions of senior clinicians who are coached to welcome learning conversations.
Simons SR, Stark RB, DeMarco RF. Research in nursing & health. 2011;34:132-40.
Disruptive behaviors are receiving increased attention as a cultural factor that contributes to medical error. Although much of the focus has been on physicians, the presence of bullying among nurses is also a concern. This magazine article explores nurse behaviors such as withholding information, intimidation, and name calling that negatively affect patient safety and nurse retention.
Stickney CA, Ziniel SI, Brett MS, et al. J Pediatr. 2014;165:1245-1251.e1.
In this study, health care providers and parents of children in a pediatric intensive care unit described their perceptions of family involvement in morning rounds. Although parents were overwhelmingly enthusiastic about being included in rounds, providers expressed some concerns and potential drawbacks, such as the avoidance of discussing uncomfortable topics due to presence of family.
Rice S. Modern healthcare. 2014;44:16-8, 20.
Language barriers can lead to misunderstandings that increase risks of error. This magazine article highlights the frequent reliance on families, friends, and other nonprofessionals as translators in medical settings and discusses how lack of standards and insufficient reporting of errors related to interpreters, along with challenges to implementing programs, hinder progress in improving communication with non-English speaking patients.
Chicago, IL: American Hospital Association Physician Leadership Forum; July 2014.
Antimicrobial stewardship has been promoted as an element of patient safety. This toolkit provides resources for hospital administrators, clinicians, and patients to help prevent overuse of antibiotics, including a readiness assessment checklist, webinars, and frequently asked questions.
NPSF Lucian Leape Institute Roundtable on Consumer Engagement in Patient Safety. Boston, MA: National Patient Safety Foundation; March 2014.
The National Patient Safety Foundation's Lucian Leape Institute recently convened two roundtables to discuss engaging patients and families in improving patient safety. This report describes the current landscape of patient engagement efforts, along with the potential benefits and challenges. To facilitate more productive partnerships in ensuring safety, the group provides recommendations and checklists for health care leaders, clinicians, patients, families, and policymakers. They advocate for patients to be equal partners in organizational and clinician care improvement activities. Patients are encouraged to feel empowered to ask questions and to actively participate in their care plans. A recent AHRQ WebM&M perspective explores the role of patient engagement in safety.
Yurkiewicz I. Aeon Magazine. January 29, 2014.
Disruptive behavior is a well-known and pervasive issue in health care. Describing disrespectful behaviors that clinicians face, such as sarcasm and intimidation, this magazine article emphasizes how they can hinder effective interactions and communication to reduce patient safety.
Knox R. Morning Edition. National Public Radio. January 27, 2014.
Reporting on alarm fatigue, this radio segment includes insights from a nurse manager and systems engineer and reveals how one hospital addressed the issue by removing low-level alerts and enabling nurses to customize alarm settings according to patient needs.
Rockville, MD: Agency for Healthcare Research and Quality; June 2013.
Studies have shown that a surprisingly large proportion of hospitalized patients are not aware of their diagnoses or treatment plan and that their preferences are often not taken into account in advanced care planning. This failure to provide patient-centered care indicates a need for increased patient engagement in safety and quality efforts. This toolkit published by the Agency for Healthcare Research and Quality is designed to help hospitals develop partnerships with patients around improving safety. Developed with input from clinicians and patients, the guide emphasizes four strategies—working with patients as advisors, improving bedside communication, integrating patients and families into shift changes, and using patient input to improve the discharge process. An AHRQ WebM&M perspective by Dr. Saul Weingart discusses the practical challenges of engaging patients in improvement efforts.
Gunderman R.
This magazine article highlights the drawbacks of amassing information in electronic medical records, in that it may negatively influence real communication or clinicians' genuine understanding of the patient.