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 1188 Results

The value of learning from near misses to improve patient safety: a scoping review.

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Woodier N, Burnett C, Moppett I. J Patient Saf. 2022;19:42-47.

Reporting and learning from adverse events is a core patient safety activity. Findings from this scoping review indicate limited evidence demonstrating that reporting and learning from near-miss events improves patient safety. The authors suggest that future research further explore this relationship and establish the effectiveness of system-level actions to avoid near misses.

Eliminating racial and ethnic disparities causing mortality and morbidity in pregnant and postpartum patients.

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Sentinel Event Alert 66;January 17, 2023:(66):1-5.

Racial and ethnic inequalities are emerging as a primary contributor to harmful maternal care. This guidance examines obstacles to safe care for mothers of color and shares recommendations to reduce disparities such as team-based care and implicit bias training.

Bleeding and in pain, a pregnant woman in Louisiana couldn’t get answers.

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Westwood R. Kaiser Health News. January 12, 2023.

Lack of access to obstetric care impedes safe treatment for mothers. This story describes challenges one mother experienced in finding care during a miscarriage due to abortion policies and the steps she and her family took to manage her condition.

Anesthesia outside of the OR: cause for patient safety concerns?

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DePeau-Wilson M. MedPage Today. January 13, 2023.

The use of anesthesia in ambulatory settings presents both advantage and risk to patients and clinicians. This article discusses evidence defining these issues. It suggests that improved collaboration with anesthesiologists represents opportunities for nonoperating room anesthesia safety.

Getting Started with a Communication and Resolution Program (CRP) Policy or Commitment Statement to CR.

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Collaborative for Accountability and Improvement Policy Committee. Seattle, WA: University of Washington; 2022

Communication and resolution programs (CRP) show promise for improving patient and clinician communication after a harmful preventable adverse event. This tool provides a framework for organizational messaging on CRPs for patients and families.

Medication use evaluation of high-dose long-term opioid de-prescribing in multiple Veterans Affairs medical centers.

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Barrett AK, Sandbrink F, Mardian A, et al. J Gen Intern Med. 2022;37:4037-4046.

Opioid medication use is associated with an increased risk of adverse events; however research has shown sudden discontinuation of opioids is also associated with adverse events such as withdrawal and hospitalization. This before and after study evaluated the impact of the VA’s Opioid Safety Initiative (OSI) on characteristics and prescribing practices. Results indicate that length of tapering period increased, and mortality risk decreased following OSI implementation.

Effect of prescriber notifications of patient’s fatal overdose on opioid prescribing at 4 to 12 months: a randomized clinical trial.

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Doctor JN, Stewart E, Lev R, et al. JAMA Netw Open. 2023;6:e2249877.

Research has shown that prescribers who are notified of a patient’s fatal opioid overdose will decrease milligram morphine equivalents (MME) up to 3 months following notification as compared to prescribers who are not notified. This article reports on the same cohort’s prescribing behavior at 4-12 months. Among prescribers who received notification, total weekly MME continued to decrease more than the control group during the 4-12 month period.

Production pressure and its relationship to safety: a systematic review and future directions.

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Hashemian SM, Triantis K. Safety Sci. 2023;159:106045.

Production pressures can inhibit effective decision-making and threaten patient safety. This systematic review examines the effects of production pressures in sociotechnical systems and discusses the need for future research to develop and implement systems to monitor and control production pressures.

Patient identification of diagnostic safety blindspots and participation in "good catches" through shared visit notes.

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Bell SK, Bourgeois FC, Dong J, et al. Milbank Q. 2022;100:1121-1165.

Patients who access their electronic health record (EHR) through a patient portal have identified clinically relevant errors such as allergies, medications, or diagnostic errors. This study focused on patient-identified diagnostic safety blind spots in ambulatory care clinical notes. The largest category of blind spots was diagnostic misalignment. Many patients indicated they reported the errors to the clinicians, suggesting shared notes may increase patient and family engagement in safety.

Medication safety incidents associated with the remote delivery of primary care: a rapid review.

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Gleeson LL, Clyne B, Barlow JW, et al. Int J Pharm Pract. 2023;30:495-506.

Remote delivery of care, such as telehealth and e-prescribing, increased sharply at the beginning of the COVID-19 pandemic. This rapid review was conducted to determine the types and frequency of medication safety incidents associated with remote delivery of primary care prior to the pandemic. Fifteen articles were identified covering medication safety and e-prescribing; none of these studies associated medication safety and telehealth.

Scaling-up a pharmacist-led information technology intervention (PINCER) to reduce hazardous prescribing in general practices: multiple interrupted time series study.

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Rodgers S, Taylor AC, Roberts SA, et al. PLoS Med. 2022;19:e1004133.

Previous research found that a pharmacist-led information technology intervention (PINCER) reduced dangerous prescribing (i.e., medication monitoring and drug-disease errors) among a subset of primary care practices in the United Kingdom (UK). This longitudinal analysis examined the impact of the PINCER intervention after implementation across a large proportion of general practices in one region in the UK. Researchers found the PINCER intervention decreased dangerous prescribing by 17% and 15% at 6-month and 12-month follow-ups, particularly among dangerous prescribing related to gastrointestinal bleeding.

How timely is diagnosis of lung cancer? Cohort study of individuals with lung cancer presenting in ambulatory care in the United States.

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Zigman Suchsland M, Kowalski L, Burkhardt HA, et al. Cancers (Basel). 2022;14:5756.

Delayed diagnosis and treatment of cancer is a serious patient safety problem. This retrospective study including 711 patients diagnosed with lung cancer used electronic health records and natural language processing (NLP) to identify relevant signs and symptoms in the two years prior to their cancer diagnosis. Researchers found that NLP can identify signs and symptoms associated with lung cancer over a year prior to diagnosis.

Balancing safety, comfort, and fall risk: an intervention to limit opioid and benzodiazepine prescriptions for geriatric patients.

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Bloomer A, Wally M, Bailey G, et al. Geriatr Orthop Surg Rehabil. 2022;13:215145932211256.

Opioid use by older adults increases the risk of falls. This study examined electronic health record data to determine the proportion of older adults presenting to the emergency room or urgent care due to a fall who receive an opioid prescription, particularly those with at least one risk factor for misuse. Nearly one third of patients received a prescription for an opioid and/or benzodiazepine, and 11% had at least one risk factor for misuse.

Impact of altering referral threshold from out-of-hours primary care to hospital on patient safety and further health service use: a cohort study.

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Svedahl ER, Pape K, Austad B, et al. BMJ Qual Saf. 2022;Epub Dec 15.

Inappropriate referrals and unnecessary hospital admissions are ongoing patient safety problems. This cohort study set in Norway examined the impact of emergency physician referral thresholds from out-of-hours services on patient outcomes.

The REPAIR Project: a prospectus for change toward racial justice in medical education and health sciences research: REPAIR project steering committee.

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REPAIR Project Steering Committee. Acad Med. 2022;97(12):1753-1759.

The REPAIR (REParations and Anti-Institutional Racism) Project at the University of California, San Francisco, aims to repair racial injustices in medical care and research. This article discusses the development of the initiative, the three annual themes (reparations, abolition, decolonization), and outcomes from its first year.

Confronting racism in pediatric care.

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Danielson B. Health Affairs. 2022;41:1681-1685.

Racism is a patient safety issue that is gaining the increased attention needed to clarify, understand, and reduce its impact. This commentary draws from a primary care pediatrician’s experience to illustrate how latent systemic racism influences decision making to affect a Black mother’s ability to care for her child with complex care needs.

Structural racism and impact on sickle cell disease: sickle cell lives matter.

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Smith WR, Valrie C, Sisler I. Hematol Oncol Clin North Am. 2022;36:1063-1076.

Racism exacerbates health disparities and threatens patient safety. This article summarizes the relationship between structural racism and health disparities in the United States and highlights how racism impacts health care delivery and health outcomes for patients with sickle cell disease.

AHRQ Safety Program for Telemedicine.

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Agency for Healthcare Research and Quality.

Telemedicine efforts harbor both risk and reward to patients and providers. The AHRQ Safety Program for Telemedicine is a national effort to develop and implement a bundle of evidence-based interventions designed to improve telemedicine care in two settings—the cancer diagnostic process and antibiotic use. To test the bundle of interventions, the program will involve two cohorts of healthcare professionals who utilize telemedicine as a care delivery model. It is an 18-month program, beginning in June 2023, that seeks to improve the cancer diagnostic process for patients who receive some or all of their care through telemedicine. Recruitment webinars start in late January and run through early May 2023; the antibiotic use cohort will begin recruitment in December 2023.

Pursuit of "endpoint diagnoses" as a cognitive forcing strategy to avoid premature diagnostic closure.

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Kaplan HM, Birnbaum JF, Kulkarni PA. Diagnosis (Berl). 2022;9:421-429.

Premature diagnostic closure, also called anchoring bias, relies on initial diagnostic impression without continuing to explore differential diagnoses. This commentary proposes a cognitive forcing strategy of “endpoint diagnosis,” or continuing to ask “why” until additional diagnostic evaluations have been exhausted. The authors describe four common contexts when endpoint diagnoses are not pursued or reached.

Accuracy in patient understanding of common medical phrases.

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Gotlieb R, Praska C, Hendrickson MA, et al. JAMA Netw Open. 2022;5:e2242972.

Ensuring patients understand their diagnosis and care plan is important to achieving optimal outcomes. However, patients routinely report not understanding what their provider has told them. In this study, adults were asked for their understanding of jargon clinicians regularly use (“negative” test results, NPO) and a corresponding statement without jargon (“you do not have an infection”, “nothing by mouth”). Some jargon was better understood (“negative”) than other jargon (“occult infection”). Participant demographics were not significantly associated with understanding jargon.

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