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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 154 Results
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. 
Tsilimingras D, Natarajan G, Bajaj M, et al. J Patient Saf. 2022;18:462-469.
Post-discharge events, such as medication errors, can occur among pediatric patients discharged from inpatient settings to home. This prospective cohort, including infants discharged from one level 4 NICU between February 2017 and July 2019, identified a high risk for post-discharge adverse events, (including procedural complications and adverse drug events) and subsequent emergency department visits or hospital readmissions. Nearly half of these events were due to management, therapeutic, or diagnostic errors and could have been prevented.
Khan A, Parente V, Baird JD, et al. JAMA Pediatr. 2022;176:776-786.
Parent or caregiver limited English proficiency (LPE) has been associated with increased risk of their children experiencing adverse events. In this study, limited English proficiency was associated with lower odds of speaking up or asking questions when something does not appear right with their child’s care. Recommendations for improving communication with limited English proficiency patients and families are presented.
Fischer H, Hahn EE, Li BH, et al. Jt Comm J Qual Patient Saf. 2022;48:222-232.
While falls are common in older adults, there was a 31% increase in death due to falls in the U.S. from 2007-2016, partially associated with the increase in older adults in the population. This mixed methods study looked at the prevalence, risk factors, and contributors to potentially harmful medication dispensed after a fall/fracture of patients using the Potentially Harmful Drug-Disease Interactions in the Elderly (HEDIS DDE) codes. There were 113,809 patients with a first time fall; 35.4% had high-risk medications dispensed after their first fall. Interviews with 22 physicians identified patient reluctance to report falls and inconsistent assessment, and documentation of falls made it challenging to consider falls when prescribing medications.
Hahn EE, Munoz-Plaza CE, Lee EA, et al. J Gen Intern Med. 2021;36:3015-3022.
Older adults taking potentially inappropriate medications (PIMs) are at increased risk of adverse events including falls. Patients and primary care providers described their knowledge and awareness of risk of falls related to PIMs, deprescribing experiences, and barriers and facilitators to deprescribing. Patients reported lack of understanding of the reason for deprescribing, and providers reported concerns over patient resistance, even among patients with falls. Clinician training strategies, patient education, and increased trust between providers and patients could increase deprescribing, thereby reducing risk of falls. 
Maloney LM, Alptunaer T, Coleman G, et al. J Emerg Med. 2020;59:872-883.
Naloxone administration in inpatient and outpatient settings is used to mitigate the effects of opioid overdose. This study, conducted at one academic medical center, found that an increasing number prehospital naloxone doses for suspected opioid overdose was significantly associated with an increased likelihood of adverse events (AEs) in the emergency department (ED).
J Patient Saf. 2020;16:s1-s56.
The patient safety evidence base has been growing exponentially for two decades with noted expansion into the non-acute care environment. This special issue highlights eight articles illustrating the range of practices examined in the AHRQ Making Healthcare Safer III report, including rapid response teams and failure to rescue, deprescribing practices and opioid stewardship.   

Holmes A, Long A, Wyant B, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2020. AHRQ Publication No. 20-0029-EF.

This newly issued follow up to the seminal AHRQ Making Health Care Safer report (first published in 2001 and updated in 2013 critically examines the evidence supporting 47 separate patient safety practices chosen for the high-impact harms they address. It includes diagnostic errors, failure to rescue, sepsis, infections due to multi-drug resistant organisms, adverse drug events and nursing-sensitive conditions. The report discusses the evidence on cross-cutting safety practices, including safety culture, teamwork and team training, clinical decision support, patient and family engagement, cultural competency, staff education and training, and monitoring, audit and feedback. The report provides recommendations for clinicians and decision-makers on effective patient safety practices.
Cullen SW, Xie M, Vermeulen JM, et al. Med Care. 2019;57:913-920.
Various factors can impact patient safety risk in psychiatric settings. This study assessed the prevalence of AEs and MEs in community hospitals and Veterans Health Administration (VHA) hospitals and found that psychiatric inpatients at community hospitals were twice as likely to experience these patient safety events than VHA inpatients, even after controlling for patient and hospital characteristics.
Harrisburg, PA: Patient Safety Authority. ISSN 2641-4716.
The Pennsylvania Patient Safety Authority is a long-established source of patient safety data analysis and application-focused commentary. Their publishing output aims to generate improvements in their state as well as throughout health care. This open-access publication replaces the quarterly Pennsylvania Patient Safety Advisory newsletter.
Kapoor A, Field T, Handler S, et al. JAMA Intern Med. 2019;179:1254-1261.
Transitions from hospitals to long-term care facilities are associated with safety hazards. This prospective cohort study identified adverse events in the 45 days following acute hospitalization among 555 nursing home residents, which included 762 discharges during the study period. Investigators found that adverse events occurred after approximately half of discharges. Common adverse events included falls, pressure ulcers, health care–associated infections, and adverse drug events. Most adverse events were deemed preventable or ameliorable. The authors conclude that improved communication and coordination between discharging hospitals and receiving long term-care facilities are urgently needed to address this patient safety gap. A previous WebM&M commentary discussed challenges of nursing home care that may contribute to adverse events.
Addiss DG, Amon JJ. Health Hum Rights. 2019;21:19-32.
Although disclosure and apology for mistakes in medical care are recommended, less is known about use of such approaches for overarching system failures. This commentary explores the use of apology in global health programs. The authors use case studies to highlight ethical, legal, and human rights principles that can be challenged when intervention design and implementation result in unintentional harm.
Maatman TC, Prigmore H, Williams JS, et al. BMJ Qual Saf. 2019;28:934-938.
This educational intervention used a comic book format to convey patient safety concepts to internal medicine residents. Awareness and confidence in patient safety topics including medication safety and fall prevention improved on the post-test compared to the pre-test, suggesting this modality has promise as a patient safety education tool.
Woeltje KF, Olenski LK, Donatelli M, et al. Joint Commission journal on quality and patient safety. 2019;45:480-486.
The Eisenberg Award honors individuals and organizations who have made important contributions to patient safety and quality improvement. Spotlighting the accomplishments of the 2018 recipients, this special issue includes an interview with Dr. Brent C. James, as well as articles on programs at The Society of Thoracic Surgeons and BJC HealthCare.

GMS J Med Educ. 2019;36:Doc11-Doc22.

Patient safety has been described as an unmet need in physician training. This special issue covers areas of focus for a patient safety curriculum drawn from experience in the German medical education system. Topics covered include human error, blame, and responsibility. Articles also review the epidemiology of common problems such as medication safety, organizational contributors to failure, and diagnostic error.
Riskin A, Bamberger P, Erez A, et al. Jt Comm J Qual Patient Saf. 2019;45:358-367.
Prior studies have demonstrated that rude behavior undermines patient safety. This study used a smartphone application to collect reports of rudeness directed toward nurses. These data were analyzed in conjunction with the hospital's hand hygiene and medication protocol compliance data as well as adverse event reports to determine if rudeness affected these safety outcomes. Participants also reported whether rudeness incidents influenced their cognition or their teamwork. Although rudeness was associated with worse self-reported cognition and teamwork, investigators did not observe differences in reported adverse events or changes in hand hygiene or medication protocol adherence related to rudeness exposure. A past PSNet perspective discussed how organizations are seeking to rehabilitate persistently disruptive clinicians.
Brewer BB, Carley KM, Benham-Hutchins MM, et al. J Nurs Adm. 2018;48:437-444.
Researchers describe the use of a social network analysis tool to examine the impact of nursing staff information sharing and advice networks on several patient safety outcomes, including medication errors, falls, and hospital-acquired pressure ulcers, across 24 medical and surgical inpatient units at 3 hospitals. They conclude that such an approach may provide supervisors with useful information for system-level change.
Sunshine JE, Meo N, Kassebaum NJ, et al. JAMA Netw Open. 2019;2:e187041.
The seminal report, To Err Is Human, famously estimated that 44,000 to 98,000 deaths per year in the United States were due to medical errors. Although certain patient harms thought to be unavoidable at the time of the report's publication in 1999 are now considered completely preventable, experts suggest that progress in the field of patient safety has been slower than initially anticipated and that areas such as ambulatory safety and diagnostic error represent emerging priorities. In this cohort study, researchers used data from 1990 through 2016 on mortality related to the adverse effects of medical treatment (AEMT) from the Global Burden of Diseases, Injuries, and Risk Factors 2016 study. For the study period, researchers attribute 123,603 deaths to AEMT. The number of such deaths increased, but the US age-standardized mortality rate for deaths due to AEMT decreased by 21% between 1990 and 2016. The authors noted similar AEMT mortality rates for men as compared to women, significantly increased AEMT mortality rates for those age 70 and older, and geographic variation with regard to age-standardized AEMT mortality rates. An Annual Perspective discussed challenges associated with measuring and responding to deaths associated with medical errors.
Washington DC; American Society of Hematology.
The American Society of Hematology produced a series of guidelines on prophylaxis for venous thromboembolism, which can be a patient safety problem among hospitalized patients. Key recommendations include low-molecular-weight heparin as the preferred agent when medication prophylaxis is indicated and screening of all hospitalized patients for venous thromboembolism risk and bleeding.
Basco WT. JAMA Netw Open. 2018;1.
The number of hospitalists—physicians practicing exclusively in acute care settings—continues to grow. However, whether patient outcomes differ between hospitalists and general physicians remains unclear. This study examined medical record data from a single urban academic children's hospital to compare patient outcomes between general pediatricians and hospitalists. After adjustment for patient characteristics (e.g., age and number of chronic conditions) and for physician characteristics (e.g., number of years in practice), the investigators did not find differences in readmission rates, total costs, or lengths of stay. The hospitalists' patients had a greater risk for device-related adverse events, which was explained by differences in physician experience. The authors conclude that the safety of care delivered by general versus hospitalist pediatricians is similar. A related editorial predicts that the hospitalist model of pediatric acute care will continue to grow.