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.
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.
Lo HG, Matheny ME, Seger DL, et al. J Am Med Inform Assoc. 2009;16:66-71.
"Alert fatigue" refers to the tendency of clinicians to ignore safety alerts—for example, warnings about potential drug interactions—if alerts are too frequent or perceived to be clinically irrelevant. However, in this study, less intrusive alerts that did not require physician response were not effective at encouraging use of recommended laboratory monitoring.
An elderly, non–English-speaking man with diabetes was admitted to the hospital twice in 8 days due to hypoglycemia. At discharge, the patient was instructed not to take any antidiabetic medications. In between hospitalizations, he saw his primary care physician, who restarted an antidiabetic medication.
A woman with a fractured right foot receives spinal anesthesia and nearly has surgery for trimalleolar fracture and dislocation of the left ankle. Only immediately prior to surgery did the team realize that the x-ray was not hers.
Shah NR, Seger AC, Seger DL, et al. J Am Med Inform Assoc. 2006;13:5-11.
In this AHRQ-funded study, the investigators sought to increase acceptance of alerts by devising specific decision support for the ambulatory care setting, with only critical alerts interrupting clinician workflow.
Please select your preferred way to submit a case. Note that even if you have an account, you can still choose to submit a case as a guest. And if you do choose to submit as a logged-in user, your name will not be publicly associated with the case. Learn more information here.