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 70 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.

Stigmatizing language expressed towards individuals with current or previous OUD who have pain and cancer: a qualitative study.

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Sedney CL, Dekeseredy P, Singh SA, et al. J Pain Symptom Manage. 2023;65:553-561.

Health professional stigma and bias towards patients with substance use disorders can impede the delivery of effective healthcare. In this qualitative analysis of medical records for 25 patients with opioid use disorder, researchers identified several markers of stigma which can impact care, including blame and stereotyping.

Curated Libraries

Implementation of Patient Safety Projects Curated Library

May 4, 2023

The implementation of effective patient safety initiatives is challenging due to the complexity of the health care environment. This curated library shares resources summarizing overarching ideas and strategies that can aid in successful program execution, establishment, and sustainability.

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.

Curated Libraries

Value and Patient Safety

March 8, 2023

Value as an element of patient safety is emerging as an approach to prioritize and evaluate improvement actions. This library highlights resources that explore the business case for cost effective, efficient and impactful efforts to reduce medical errors.

Curated Libraries

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. ...

Curated Libraries

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.

Effect of different interventions to help primary care clinicians avoid unsafe opioid prescribing in opioid-naive patients with acute noncancer pain: a cluster randomized clinical trial.

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Kraemer KL, Althouse AD, Salay M, et al. JAMA Health Forum. 2022;3:e222263.

Nudges (e.g., default order sets) in the electronic health record (EHR) have been shown to encourage safer prescribing of opioids in emergency departments. This study evaluated the effect of nudges to reduce opioid prescribing for opioid-naïve patients with acute pain. Primary care practices were cluster randomized to control, opioid justification in the EHR, peer comparison, or combined opioid justification and peer comparison groups. The three intervention groups showed reduced opioid prescribing compared to control.

Annual Perspective: Topics in Medication Safety

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Perspective on Safety March 31, 2022

Errors in medication management and administration are major threats to patient safety. This piece explores issues with opioid and nursing-sensitive medication safety as well as medication safety in older adults. Future research directions in medication safety are also discussed.

Curated Libraries

Medication/Drug Errors

January 14, 2022

The medication-use process is highly complex with many steps and risk points for error, and those errors are a key target for improving safety. This Library reflects a curated selection of PSNet content focused on medication and drug errors. Included resources explore understanding harms from preventable medication use, medication safety...

Curated Libraries

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.

Hyponatremia Secondary to Home Parenteral Nutrition Error

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WebM&M Case May 26, 2021

A 4-year-old (former 33-week premature) boy with a complex medical history including gastroschisis and subsequent volvulus in infancy resulting in short bowel syndrome, central venous catheter placement, and home parenteral nutrition (PN) dependence was admitted with hyponatremia. A pharmacist from the home infusion pharmacy notified the physician that an error in home PN mixing had been identified; a new file had been created for this chronic PN patient by the home infusion pharmacy and the PN formula in this file was transcribed erroneously without sodium acetate.

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.

Reducing inappropriate outpatient medication prescribing in older adults across electronic health record systems.

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Friebe MP, LeGrand JR, Shepherd BE, et al. Appl Clin Inform. 2020;11:865-872.

The prescribing of potentially inappropriate medications, particularly among older adults, is an ongoing quality and safety concern. Among adults 65 years and older, this study found that clinical decision support integrated with a new electronic health record system significantly reduced potentially inappropriate medications.

Discrepancies in written versus calculated durations in opioid prescriptions: pre-post study.

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Slovis BH, Kairys J, Babula B, et al. JMIR Med Inform. 2020;8.

This study examined differences in the treatment duration written in an opioid prescription versus the duration associated with the dosing frequency and number of pills per day. Over a 22-month period, nearly 17% of opioid prescriptions were for a duration greater than what was documented in the prescription. The study found that making the opioid prescription duration a required field in the electronic health record (EHR) reduced the discrepancy between the written and calculated durations but did not eliminate the discrepancies.

ISMP Guidelines for Optimizing Safe Implementation and Use of Smart Infusion Pumps.

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Institute for Safe Medication Practices. Horsham, PA: Institute for Safe Medication Practices; 2020.

Smart pumps are widely available as a medication safety tool yet there are challenges affecting their reliable use. This guideline expands on earlier recommendations to support smart pump use in both hospitals and the ambulatory setting. The material provides recommendations that address infrastructure, drug libraries, quality improvement data, workflow and electronic health record interoperability concerns.

A Mistaken Dose of Naloxone 

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WebM&M Case December 18, 2019

A 55-year-old man visited his oncologist for a follow-up appointment after completing chemotherapy and reported feeling well with his abdominal and bony pain well controlled with opioid therapy. At the end of the visit, his oncologist reordered his pain medication and, due to a best practice alert, also prescribed naloxone but failed to provide any instruction on its use. Later that day, the patient took the naloxone along with his opioid pain medication and within a minute experienced severe abdominal and bony pain, requiring admission to the emergency department.

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.

Automated detection of wrong-drug prescribing errors.

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Lambert BL, Galanter W, Liu KL, et al. BMJ Qual Saf. 2019;28:908-915.

Look-alike and sound-alike (LASA) drugs are a well-established source of medication errors that place patients at risk for adverse drug events. Prior research has shown that these medications can be automatically identified using diagnostic codes at the time of electronic prescribing. Using electronic health record data on medication orders and diagnostic claims data from a single academic medical center as well as data on medication indications, researchers developed an algorithm to identify LASA prescribing errors. Although the algorithm was able to identify LASA prescribing errors that may not have been found by other means, the positive predictive value was 12.1% and the false-positive rate was greater than 75%. The authors advocate for further research to improve specificity and sensitivity of this approach. A past WebM&M commentary discussed a case involving the mix-up of two medications with similar names.

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