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 127 Results

Delay in Malignancy Diagnosis Reflects Systemic Failures.

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WebM&M Case October 31, 2023

A 32-year-old man presented to the hospital with a comminuted midshaft femoral fracture after a bicycle accident. Imaging suggested the fracture was pathologic and an open biopsy specimen was submitted to pathology for intraoperative consultation.

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Patient as a Team Member in Clinical Care

October 23, 2023

This curated library highlights concepts associated with the patient as a partner for safety at the team level directly connected to personal clinical encounters.

Failure to adhere to dietary restrictions leading to complications and poor follow-up.

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WebM&M Case July 31, 2023

A 50-year-old unhoused patient presented to the Emergency Department (ED) for evaluation of abdominal pain, reportedly one day after swallowing multiple sharp objects. Based on the radiologic finding of an open safety pin or paper clip in the distal stomach, he was appropriately scheduled for urgent esophagogastroduodenoscopy and ordered to remain NPO (nothing by mouth) to reduce the risk of aspirating gastric contents.

Improving Diagnostic Safety and Quality

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Perspective on Safety April 26, 2023

Throughout 2022, AHRQ PSNet has shared research that elucidates the complex nature of misdiagnosis and diagnostic safety. This Year in Review explores recent work in diagnostic safety and ways that greater safety may be promoted using tools developed to improve diagnostic practices.

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Diagnostic Errors Case Studies

January 19, 2023

The Primary-Care Research in Diagnosis Errors (PRIDE) Learning Network was a Boston-based national effort to improve diagnostic safety. Hosted by the State of Massachusetts’ Betsy Lehman Center, it was led by the Harvard Brigham and Women’s Center for Patient Safety Research and Practice with funding from the Gordon and Betty Moore Foundation. ...

Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions

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Perspective on Safety November 16, 2022

Human factors engineering or ergonomics (HFE) is a scientific discipline broadly focused on interactions among humans and other elements of a system.

In Conversation with Dr. Michelle Schreiber on Measuring Patient Safety

We spoke to Dr. Michelle Schreiber about measuring patient safety, the CMS National Quality Strategy, and the future of measurement. Michelle Schreiber, MD, is the Deputy Director of the Center for Clinical Standards and Quality and the Director of the Quality Measurement and Value-Based Incentives Group at the Centers for Medicare & Medicaid Services.

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Diagnostic Safety

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.

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Maternal Safety

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.

Missed acute coronary syndrome during telephone triage at out-of-hours primary care: lessons from a case-control study.

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Erkelens DC, Rutten FH, Wouters LT, et al. J Patient Saf. 2022;18:40-45.

Delays in diagnosis and treatment during after-hours care pose serious threats to patient safety. This case-control study compared missed acute coronary syndrome (ACS) cases to other cases with chest discomfort occurring during out-of-hours services in primary care. Predictors of missed ACS included the use of cardiovascular medication, non-retrosternal chest pain, and consultation of the supervising general practitioner.

Speaking up about patient-perceived serious visit note errors: patient and family experiences and recommendations.

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Lam BD, Bourgeois FC, Dong ZJ, et al. J Am Med Inform Assoc. 2021;28:685-694.

Providing patients access to their medical records can improve patient engagement and error identification. A survey of patients and families found that about half of adult patients and pediatric families who perceived a serious mistake in their ambulatory care notes reported it, but identified several barriers to reporting (e.g. no clear reporting mechanism, lack of perceived support).

Patient Safety 101

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Patient Safety Primer September 7, 2019

This Primer provides an overview of the history and current status of the patient safety field and key definitions and concepts. It links to other Patient Safety Primers that discuss the concepts in more detail.

Ensuring effective care transition communication: implementation of an electronic medical record-based tool for improved cancer treatment handoffs between clinic and infusion nurses.

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Pandya C, Clarke T, Scarsella E, et al. J Oncol Pract. 2019;15:e480-e489.

Care transitions and handoffs represent a vulnerable time for patients, as failure to communicate important clinical information may occur with the potential for harm. In this pre–post study, researchers found that implementation of an electronic health record tool designed to improve the handoff between oncology clinic and infusion nurses was associated with a reduction in medication errors, shorter average patient waiting time, and better communication between nurses.

Ambulatory safety nets to reduce missed and delayed diagnoses of cancer.

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Emani S, Sequist TD, Lacson R, et al. Jt Comm J Qual Patient Saf. 2019;45:552-557.

Health care systems struggle to ensure patients with precancerous colon and lung lesions receive appropriate follow-up. This academic center hired navigators who effectively increased the proportion of patients who completed recommended diagnostic testing for colon polyps and lung nodules. A WebM&M commentary described how patients with lung nodules are at risk for both overtreatment and undertreatment.

The MedSafer Study: a controlled trial of an electronic decision support tool for deprescribing in acute care.

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McDonald EG, Wu PE, Rashidi B, et al. J Am Geriatr Soc. 2019;67:1843-1850.

This pre–post study compared patients who received medication reconciliation that was usual care at the time of hospital discharge to patients in the intervention arm who had decision support for deprescribing. Although the intervention did lead to more discontinuation of potentially inappropriate medications, there was no difference in adverse drug events between groups. The authors suggest larger studies to elucidate the potential to address medication safety using deprescribing decision support.

An opportunity to engage obstetrics and gynecology patients through shared visit notes.

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Herlihy M, Harcourt K, Fossa A, et al. Obstet Gynecol. 2019;134:128-137.

Prior research has shown that when patients have access to clinicians' notes, they may identify relevant safety concerns. In this study, 9550 obstetrics and gynecology patients were provided with access to their outpatient visit documentation. Almost 70% of eligible patients read one or more notes during the study period, but only 3.2% shared feedback through 232 electronic reports. Of patients who provided feedback, 27% identified errors in the documentation; provider reviewers determined that 75% of these could impact care.

Delayed Sepsis Management Due to Ambiguous Allergy

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WebM&M Case June 1, 2019

Transferred to the emergency department from the transfusion center after becoming unresponsive and hypotensive, an elderly man with signs of sepsis is given incomplete and delayed antimicrobial coverage due to a history of penicillin allergy. Neither gram-negative nor anaerobic coverage were provided until several hours later, and the patient developed septic shock.

Deny, Dismiss, Dehumanise: What Happened When I Went to Hospital.

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Cullen A. Uitgeverij van Brug: The Hague, The Netherlands; 2019. ISBN: 9789065232236.

Patient stories offer important insights regarding the impact medical errors have on patients and their families. This book shares the author's experience with medical error and spotlights how lack of transparency in European health care can contribute to avoidable process failures that result in patient harm.

Does a unit shift report "blackout" period improve patient safety?

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Olmstead J. Nurs Manage. 2019;50:8-10.

Mistakes during handoffs from the emergency department (ED) to inpatient units can diminish patient safety. This commentary summarizes how one hospital sought to to avoid miscommunications and disruptions by blocking admission of ED transfers during shift report. However, researchers found that blocking patient transfers did not result in improvements. The project did devise a standardized handoff process that was ultimately employed across the organization as a patient safety strategy.

Evaluation of medication errors at the transition of care from an ICU to non-ICU location.

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Tully AP, Hammond DA, Li C, et al. Crit Care Med. 2019;47:543-549.

Transitions of care, whether from the hospital to the outpatient setting or within the hospital itself, represent a vulnerable time for patients. Inadequate communication during handoffs that occur as part of care transitions can contribute to adverse events and errors, including medication errors. This study of 58 intensive care units (ICUs) across 34 United States hospitals and 2 Dutch hospitals sought to assess medication errors among patients transferred from ICUs. Of the 985 patients included in the study, almost half (46%) experienced a medication error during transition out of the ICU. Discontinuing orders and reordering medications at the time of transfer out of the ICU as well as daily patient rounding in the ICU were associated with decreased odds of medication error during transition. A past Annual Perspective discussed challenges associated with handoffs and transitions of care.

Duplicate Insulin Order

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WebM&M Case March 1, 2019

Seen in the emergency department, a man with insulin-dependent diabetes mellitus had not taken insulin for 3 days. His blood glucose levels were in the 800s with an anion-gap acidosis and positive beta hydroxybutyrate. While awaiting an ICU bed for treatment of diabetic ketoacidosis, the patient received fluids, an insulin drip was started, and blood glucose levels were monitored hourly. When lab results showed he was improving, the team decided to convert his insulin drip to subcutaneous long-acting insulin.

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