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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 58 Results
WebM&M Case September 27, 2023

A 42-year-old man with a history of posttraumatic stress disorder (PTSD), alcohol use disorder and anxiety disorder, was seen in the emergency department (ED) after a high-risk suicide attempt by hanging. The patient was agitated and attempted to escape from the ED while on an involuntary psychiatric commitment. The ED staff treated him as a “routine boarder” awaiting an inpatient bed, with insufficiently robust behavioral monitoring.

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.

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
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. ...
Kaplan HM, Birnbaum JF, Kulkarni PA. Diagnosis (Berl). 2022;9:421-429.
Premature diagnostic closure, also called anchoring bias, relies on initial diagnostic impression without continuing to explore differential diagnoses. This commentary proposes a cognitive forcing strategy of “endpoint diagnosis,” or continuing to ask “why” until additional diagnostic evaluations have been exhausted. The authors describe four common contexts when endpoint diagnoses are not pursued or reached.
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.
WebM&M Case August 31, 2022

A 49-year-old woman was referred by per primary care physician (PCP) to a gastroenterologist for recurrent bouts of abdominal pain, occasional vomiting, and diarrhea. Colonoscopy, esophagogastroduodenoscopy, and x-rays were interpreted as normal, and the patient was reassured that her symptoms should abate. The patient was seen by her PCP and visited the Emergency Department (ED) several times over the next six months. At each ED visit, the patient’s labs were normal and no imaging was performed.

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.
Abdelhadi N, Drach‐Zahavy A, Srulovici E. J Adv Nurs. 2020;76:2161-2170.
This qualitative study conducted focus groups with 28 registered nurses working in different hospital settings to explore perspectives regarding decision-making and personal or contextual attributes leading to missed nursing care.  Three themes emerged based on the analysis: missed nursing care can result due to scarce resources or nurses’ agency, differences in thinking based on routine or novel situations, and situational factors triggering fluctuations in their awareness (such as difficult patients or the presence of family). The authors suggest that organizational training programs should encourage nurses to identify barriers and facilitators of missed nursing care and approaches to overcome these factors.
WebM&M Case December 18, 2019
A 62-year-old man with a history of malnutrition-related encephalopathy was admitted for possible aspiration pneumonia complicated by empyema and coagulopathy. During the hospitalization, he was uncooperative and exhibited signs of delirium. For a variety of reasons, he spent two weeks in the hospital with minimal oral intake and without receiving most of his oral medications, putting him at risk for complications and adverse outcomes.
WebM&M Case December 18, 2019
A 63-year-old woman with hematemesis was admitted by a 2nd year medical resident for an endoscopy. The resident did not spend adequate time discussing her code status and subsequently, made a series of errors that failed to honor the patient’s preferences and could have resulted in an adverse outcome for this relatively healthy woman.
O'Toole JK, Starmer AJ, Calaman S, et al. MedEdPORTAL. 2019;15:10794.
Champions play critical roles for implementing change in organizations. This commentary reports the results of a program to train champions of the I-PASS handoff program. The initiative used a set of tools and educational tactics to build frontline leaders' skills to mentor standardized handoffs behaviors at 32 locations. The process and tools were considered by participants as instrumental in the success of leading staff to adopt I-PASS techniques at the institutions.
WebM&M Case February 1, 2019
Following surgery under general anesthesia, a boy was extubated and brought to postanesthesia care unit (PACU). Due to the patient's age and length of the surgery, the PACU anesthesiologist ordered continuous pulse-oximetry monitoring for 24 hours. Deemed stable to leave the PACU, the boy was transported to the regular floor. When the nurse went to place the patient on pulse oximetry, she realized he was markedly hypoxic. She administered oxygen by face mask, but he became bradycardic and hypotensive and a code blue was called.
WebM&M Case January 1, 2019
A woman with a history of psychiatric illness presented to the emergency department with agitation, hallucinations, tachycardia, and transient hypoxia. The consulting psychiatric resident attributed the tachycardia and hypoxia to her underlying agitation and admitted her to an inpatient psychiatric facility. Over the next few days, her tachycardia persisted and continued to be attributed to her psychiatric disease. On hospital day 5, the patient was found unresponsive and febrile, with worsening tachycardia, tachypnea, and hypoxia; she had diffuse myoclonus and increased muscle tone.
Whitehead NS, Williams L, Meleth S, et al. J Hosp Med. 2018.
Test results pending at the time of hospital discharge can lead to a delay in diagnosis and represent a significant patient safety risk. This systematic review found that certain electronic and educational interventions may improve documentation and awareness of pending test results. The authors suggest that further research is needed to understand how these interventions affect processes and outcomes.
WebM&M Case March 1, 2018
One day after reading only the first line of a final ultrasound result (which stated that the patient had a thrombosis), an intern reported to the ICU team that the patient had a DVT. Because she had postoperative bleeding, the team elected to place an inferior vena cava (IVC) filter rather than administer anticoagulants to prevent a pulmonary embolism (PE). The next week, a new ICU team discussed the care plan and questioned the IVC filter.
WebM&M Case October 1, 2017
Hospitalized with sepsis secondary to an infected IV line through which she was receiving treprostnil (a high-alert medication used to treat pulmonary hypertension), a woman was transferred to interventional radiology for placement of a new permanent catheter once the infection cleared. Sign-off between departments included a warning not to flush the line since it would lead to a dangerous overdose. However, while attempting to identify an infusion pump alarm, a radiology technician accidentally flushed the line, which led to a near code situation.
Nanchal R, Aebly B, Graves G, et al. BMJ Qual Saf. 2017;26:987-992.
Communication errors during handoffs can lead to patient harm. Standardizing the handoff process has been shown to improve patient safety. This prospective trial demonstrated that implementation of a standardized intensive care unit sign-out process among residents led to fewer unexpected patient events and unplanned interventions.
Vanderbilt AA, Pappada SM, Stein H, et al. Adv Med Educ Pract. 2017;8:365-367.
Handoffs are vulnerable to communication missteps, and they are further complicated when complex patients such as neonates are involved. This commentary suggests that interprofessional simulation and communication tools can help teams build skills required for reliable and effective handoffs.