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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 - 19 of 19 Results
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.
Raghuram N, Alodan K, Bartels U, et al. Virchows Archiv. 2021;478:1179-1185.
Autopsies are an important tool for identifying diagnostic errors. This retrospective study of 821 pediatric cancer deaths found that 10% had a major diagnostic discrepancy between antemortem and postmortem diagnoses. These discrepancies primarily consisted of missed infections, missed cancer diagnoses, and organ complications.
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, collaborative initiatives, teamwork, and trigger tools.
Dadlez NM, Adelman JS, Bundy DG, et al. Ped Qual Saf. 2020;5:e299-e305.
Diagnostic errors, including missed diagnoses of adolescent depression, elevated blood pressure, and delayed response to abnormal lab results, are common in pediatric primary care. Building upon previous work, this study used root cause analyses to identify the failure points and contributing factors to these errors. Omitted process steps included failure to screen for adolescent depression, failure to recognize and act on abnormal blood pressure values, and failure to notify families of abnormal lab results. Factors contributing most commonly to these errors were patient volume, inadequate staffing, clinic environment, electronic and written communication, and provider knowledge.
Williams S, Fiumara K, Kachalia A, et al. Jt Comm J Qual Saf. 2020;46:44-50.
A lack of closed-loop feedback systems has been identified as one contributor to underreporting of patient safety events. This paper describes one large academic medical center’s implementation of a Feedback to Reporter program in ambulatory care, which aimed to ensure feedback on safety reports is provided to reporting staff by managers. At baseline, 50% of staff who requested feedback ultimately received it; after three years, the rate of feedback to reporters had increased to 90%.
Desai S, Fiumara K, Kachalia A. J Patient Saf. 2021;17:e84-e90.
Outpatient safety is gaining recognition as a focus of research and improvement efforts. This project report describes an ambulatory safety program at an academic health system that targeted reporting, safety culture measurement, medication safety, and test result management. Repeated tracking over a 5-year period revealed that failure to request feedback played a role in the modest incident and concern reporting captured by the program. Decentralizing reporting response responsibilities throughout the system significantly increased feedback activity.
Ai A, Desai S, Shellman A, et al. Jt Comm J Qual Patient Saf. 2018;44:674-682.
This study examined ambulatory follow-up of test results by aggregating multiple types of data—national surveys on safety culture and patient satisfaction; patient complaints; safety reports; and electronic health record audits of provider response times. Researchers found an association between quicker response time for test results and higher patient satisfaction. They conclude that merging these disparate data sources can uncover new levers to improve patient safety.
Grant S, Checkland K, Bowie P, et al. Implement Sci. 2017;12:56.
Test result management is a critical aspect of ambulatory patient safety. This direct observation study identified highly variable strategies across outpatient practices with different vulnerabilities. These results underscore the need to develop interventions to enhance management of test results.
Bowie P, Price J, Hepworth N, et al. BMJ Open. 2015;5:e008968.
This retrospective study of abnormal laboratory test orders and results in primary care uncovered multiple vulnerabilities, similar to prior studies. The authors describe a conceptual model to comprehensively address the safety of laboratory testing and results management in primary care, a useful step for future interventions.
Williams H, Edwards A, Hibbert P, et al. Br J Gen Pract. 2015;65:e829-e837.
Adverse events after hospital discharge are common, affecting nearly 20% of patients within 3 weeks of discharge. This study used data from the United Kingdom's National Reporting and Learning System to analyze the contributors to these adverse events. Principal contributing factors included inadequate discharge communication between hospital-based and outpatient physicians and insufficient assessment of patients' need for community-based services.
Gillies D, Chicop D, O'Halloran P. Crisis. 2015;36:316-324.
This study used root cause analysis to identify underlying causes of suicide among mental health service clients. Researchers found that most patients had denied suicidal ideation and had missed follow-up in their mental health care. Their results underscore the challenge of preventing suicide in patients with mental illness.
Kumar P, Biswas A, Iyengar H, et al. Jt Comm J Qual Patient Saf. 2015;41:228-233.
Interviews with mothers were compared with maternal prenatal histories and infant medical records in this study, revealing that a majority of patients had at least one information gap in which pertinent data was not recorded in the medical record. While such incomplete information has been documented previously, these errors of omission raise concern for adverse events and demonstrate the need for new strategies.
Callen JL, Westbrook JI, Georgiou A, et al. J Gen Intern Med. 2011;27:1334-1348.
Following up test results in a timely fashion is a recognized patient safety problem in primary care, and inadequate follow-up systems are a source of frustration for outpatient clinicians and a relatively common source of malpractice claims. This systematic review found evidence that failure to act on abnormal radiology or laboratory results is common and clearly linked to missed or delayed diagnoses. The review also found wide variation in processes for handling test results across studies. Electronic health records (EHRs) did appear to improve test follow-up rates, although a substantial proportion of abnormal results were not followed up even with EHRs. The authors advocate for more standardized processes for informing patients of abnormal results, and recent guidelines have been published for organizational policies to improve test result communication.
Weingart SN, Price J, Duncombe D, et al. Jt Comm J Qual Patient Saf. 2007;33:83-94.
This study assessed the ability of patients to detect medical errors through an innovative mechanism of using patient safety liaisons (trained patient and family volunteers) to conduct interviews of patients at an outpatient chemotherapy center. Patients' responses to open-ended questions were reviewed by physicians, who classified reported adverse events as adverse events, near misses, or problems with service quality (eg, delays or poor communication). Patients demonstrated good understanding of safe practices in outpatient chemotherapy, and nearly one-fourth of the patients felt they had experienced unsafe care. However, only 1% of the reported events were classified as true medical errors with potential for harm. The vast majority of events related to service quality rather than quality of care. Prior research also assessed the relationship between patient perceptions of care quality and service quality.
Gandhi TK, Kachalia A, Thomas EJ, et al. Ann Intern Med. 2006;145:488-496.
Medical errors in the outpatient setting have remained a relatively understudied aspect of patient safety. This study analyzed data from malpractice claims at four liability insurers, similar to companion studies of errors in surgical and emergency department patients, to determine the frequency and causes of missed and delayed diagnoses. Diagnostic errors resulting in patient harm occurred in 181 cases, chiefly consisting of missed or delayed diagnoses of cancer. Failure to reach a timely diagnosis was generally due to multiple process breakdowns, including failure to order an appropriate diagnostic test and inadequate follow-up planning, many of which could be ascribed to physician cognitive errors. As with prior studies using chart review, reviewer's agreement on whether an error occurred was only moderate. The authors note that due to the complexity of contributing factors to outpatient errors, simple solutions are unlikely. An accompanying editorial, available via the link below, considers the differences in the nature of errors and approaches to solving them between the inpatient and outpatient settings and calls for greater attention to tackling outpatient safety issues.