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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 1397 Results
The Joint Commission.
The National Patient Safety Goals (NPSGs) are one of the major methods by which The Joint Commission establishes standards for ensuring patient safety in all health care settings. In order to ensure health care facilities focus on preventing major sources of patient harm, The Joint Commission regularly revises the NPSGs based on their impact, cost, and effectiveness. Major focus areas include promoting surgical safety and preventing hospital-acquired infections, medication errors, inpatient suicide, and specific clinical harms such as falls and pressure ulcers. The 2023 goals are now available.
O’Hare AM, Vig EK, Iwashyna TJ, et al. JAMA Netw Open. 2022;5:e2240332.
Long COVID-19 can be challenging to diagnose. Using electronic health record (EHR) data from patients receiving care in the Department of Veterans Affairs, this qualitative study explored the clinical diagnosis and management of long COVID symptoms. Two themes emerged – (1) diagnostic uncertainty about whether symptoms were due to long COVID, particularly given the absence of specific clinical markers and (2) care fragmentation and poor care coordination of post-COVID-19 care processes.
Dowell D, Ragan KR, Jones CM, et al. MMWR Recomm Rep. 2022;71:1-95.
In 2016, the Centers for Disease Control and Prevention (CDC) released guidelines for safe opioid prescribing for chronic pain. Based on an updated evidence review, the CDC has revised the guidelines and released the Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022, include recommendations for outpatient acute, subacute, and chronic opioid use. The twelve recommendations fall into four broad categories: determining whether or not to initiate opioids for pain; selecting opioids and determining opioid dosages; deciding duration of initial opioid prescription and conducting follow-up; and assessing risk and addressing potential harms of opioid use. The CDC will update and develop tools and resources to support dissemination of these guidelines. The recommendations do not apply to pain related to sickle cell disease or cancer or to patients receiving palliative or end-of-life care, or for patients in the emergency department or admitted to the hospital.

Schneider E, Koretz BK, eds. Clin Geriatr Med. 2022;38(4):621-732.

Polypharmacy is a known contributor to medication complexity and error. This special issue examines the impact unnecessary medications have in a variety of care environments, such as nursing homes and emergency departments, and clinical areas, such as oncology and behavioral health.

Institute for Safe Medication Practices.

Mixed case letters are one suggested strategy to reduce look-alike medication name errors. This survey announcement calls for insight from the field to update an existing resource of problematic drug name pairs and examine the effectiveness of mixed case letter use to minimize confusion. The deadline for comment submission is December 2, 2022.
Laing L, Salema N-E, Jeffries M, et al. PLoS ONE. 2022;17:e0275633.
Previous research found that the pharmacist-led IT-based intervention to reduce clinically important medication errors (PINCER) can reduce prescription and medication monitoring errors. This qualitative study explored patients’ perceived acceptability of the PINCER intervention in primary care. Overall perceptions were positive, but participants noted that PINCER acceptability can be improved through enhanced patient-pharmacist relationships, consistent delivery of PINCER-related care, and synchronization of medication reviews with prescription renewals.
Rockville, MD: Agency for Healthcare Research and Quality.
In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. The 2022 report discusses a decrease in life expectancy due to the COVID-19 pandemic. It also reviews the current status of special areas of interest such as maternity care, child and adolescent mental health, and substance abuse disorders. 
Roberts TJ, Sellars MC, Sands JM, et al. JCO Oncol Pract. 2022;Epub Sep 1.
Missed diagnosis of infectious diseases can have serious consequences for patient safety. This article describes a delayed diagnosis of disseminated tuberculosis in a patient with lung cancer and discusses the how cognitive biases and systems failures contributed to the diagnostic error.

Schiff G. Chapter In: Loscalzo J, Fauci A, Kasper D, et al, eds. Harrison's Principles of Internal Medicine, 21e. New York, NY: McGraw Hill; 2022

The task of performing a safe diagnosis has gone beyond the use of technical skill and knowledge. This book chapter introduces the application of intersecting concepts such as human factors engineering, cognition, information technology, and learning systems to achieve diagnostic improvement.
Wong J, Lee S-Y, Sarkar U, et al. Am J Health Syst Pharm. 2022;Epub Sep 27.
Medication errors in ambulatory care settings represent an ongoing patient safety challenge. This study characterizes ambulatory care adverse drug events reported to a large patient safety organization between May 2012 and October 2018. Anticoagulants, antibiotics, hypoglycemics, and opioids were the most commonly involved medication classes. Contributing factors included prescribing errors, failure to review clinical contraindications or drug-drug interactions, and lack of patient education or communication.
Soled KRS, Dimant OE, Tanguay J, et al. BMC Health Serv Res. 2022;22:1134.
Transgender and gender-diverse people can face discriminatory behaviors when accessing health care services. This qualitative study explored clinician perspectives with regard to practicing transgender health care. Findings indicate that stigma, gatekeeping, and knowledge deficits are barriers to high-quality care delivery but respondents also highlighted strategies for successful care delivery, including mentorship and use of a person-centered approach to care.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; September 29, 2022.

Recalls of medications due to labeling errors are an established approach to minimize the potential for harm. This announcement highlights a labeling mistake with hypertension and antiplatelet medications that could result in dose omissions or bleeding risk.
Singh H, Mushtaq U, Marinez A, et al. Jt Comm J Qual Patient Saf. 2022;48:581-590.
Diagnostic error continues to be a significant safety problem. Using a multimethod approach, this study developed a checklist of ten high-priority practices for diagnostic excellence which healthcare organizations can implement to address diagnostic errors. Priority practices include promoting speaking up behaviors through a just culture and psychologically safe environment; patient and family engagement in identifying, understanding, and addressing diagnostic safety concerns; and using multidisciplinary perspectives (including human factors and informatics) to understand factors contributing to diagnostic safety events.
Curated Libraries
October 10, 2022
Selected PSNet materials for a general safety audience focusing on improvements in the diagnostic process and the strategies that support them to prevent diagnostic errors from harming patients.
Ayalew MB, Spark MJ, Quirk F, et al. Int J Clin Pharm. 2022;44:860-872.
Patients with diabetes, particularly those taking multiple medications, are at increased for medication adverse events. In this review of nearly 200 studies of potentially inappropriate prescribing (PIP) for patients with diabetes, several types of PIPs occurred: contraindication, omission, incorrect dosing, drug-drug interaction, inappropriate drug selection, and unnecessary drug therapy.

Tahir D. Kaiser Health News. September 26, 2022. 

Negative patient representations in medical records perpetuate stereotypes that can affect care over time. This story discusses how written notes using stigmatizing language reflect bias and physician disrespect that serve as clues to misdiagnosis. Black patients and those patients named as "difficult" were particularly vulnerable to damaging representation in notes.
Perspective on Safety September 28, 2022

Special thanks to Freya Spielberg, MD, MPH, Founder and CEO of Urgent Wellness LLC in Washington, DC; and Jack Westfall, MD, MPH, Director of the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, for their thoughtful interviews on the topic of Primary Care and Patient Safety, which helped lay the groundwork for this Perspective.