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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 33 Results
Perspective on Safety November 16, 2022

Dr. Pascale Carayon, PhD, is a professor emerita in the Department of Industrial and Systems Engineering and the founding director of the Wisconsin Institute for Healthcare Systems Engineering (WIHSE). Dr. Nicole Werner, PhD, is an associate professor in the Department of Health and Wellness Design at the Indiana University School of Public Health-Bloomington. We spoke with both of them about the role of human factors engineering has in improving healthcare delivery and its role in patient safety.

Wyner D, Wyner F, Brumbaugh D, et al. Pediatrics. 2021;148:e2021053091.
The dismissal of parental concerns is a known contributor to medical errors in children. This story illustrates how poor communication, lack of respect, and anchoring bias  contributed to failure in the care of a boy. The authors share actions being taken by the hospital involved in the tragedy to partner with the family to improve diagnosis practices throughout their organization.
WebM&M Case July 28, 2021

This commentary presents two cases highlighting common medication errors in retail pharmacy settings and discusses the importance of mandatory counseling for new medications, use of standardized error reporting processes, and the role of clinical decision support systems (CDSS) in medical decision-making and ensuring medication safety.

Hart WM, Doerr P, Qian Y, et al. AMA J Ethics. 2020;22:E298-E304.
Communication has become a foci of improvement efforts across the spectrum of patient safety. This article discusses a surgical complication incident that illustrates the importance of transparency, disclosure and collaboration as elements of a successful approach to communication that can successfully manage the impact of an adverse incident.
Brown SD, Bruno MA, Shyu JY, et al. Radiology. 2019;293:30-35.
This commentary reviews general aspects of the disclosure movement, supportive evidence, and challenges associated with liability concerns. The authors discuss barriers unique to radiology that have hindered acceptance of the practice and highlight how communication-and-resolution programs can support radiologist participation in disclosure conversations.
Byju AS, Mayo K. J Med Ethics. 2019;45:821-823.
Managing errors that affect patients who lack decision-making capacity and a designated decision-maker is a new area of concern. This commentary discusses moral, ethical, legal, and clinical reasons for health care to examine how to respond when such a situation occurs. The authors hope to motivate development of needed protocols and best practices to ensure that this vulnerable patient population is respectfully and completely informed after medical errors.
Antunez AG, Saari A, Miller J, et al. Ann Surg. 2021;273:516-522.
Clinicians sometimes need to address errors committed by other providers, who may or may not be part of their own organization. This study used simulated cases to explore patient preferences for error disclosure when the disclosing provider was not involved in the error. Patients strongly preferred that these errors be treated similarly to other errors, asking for full disclosure whenever possible. A review article and a WebM&M commentary discuss frameworks for providers to use when disclosing errors committed by another clinician.
National Quality Forum
This website tracks the progress of a project focused on the development and review of measures to enhance viability, reporting, accountability, and impact of health care organization efforts to reduce diagnostic error. The committee's final report is now available.
Chiu RG. AMA J Ethics. 2019;21:E553-558.
Although disclosure of medical error to patients is difficult, it is an ethical responsibility. This article discusses situations involving patients who are incapacitated and unrepresented but have no surrogate present to assist in communication and care coordination. Despite this challenge, the author argues that the clinician and organization still have the responsibility to document what happened, communicate what is known, and rectify the mistake.
Palmer J. Patient Saf Qual Healthc. May/June 2019.
Organizations must learn from adverse events to prevent similar incidents. Reporting on lessons to be learned from the cascade of failures connected with the preventable death of a patient during an acute asthma attack at the door of a hospital emergency department, this magazine article outlines the importance of effective signage, appropriate security staff placement, and acceptance of the responsibility for failure.
Blease CR, Bell SK. Diagnosis (Berl). 2019;6:213-221.
Despite growing support for patient involvement in safety and quality improvement, little is known about engaging patients as partners in reducing diagnostic error. This commentary summarizes research on how sharing notes with patients can improve the timeliness of follow-up to confirm a diagnosis, identify documentation errors, and strengthen communication between the clinical team and the patient. The authors discuss challenges to the successful implementation of this strategy and areas of focus needed for future development. A PSNet interview discussed use of OpenNotes to engage patients in their care.
Pettersen B, Tate J, Tipper K, McKean H. Colorado Senate Bill 19-201.
Communication-and-resolution mechanisms are seen as important approaches to improving transparency and healing after an adverse event. This state bill, referred to as the "Colorado Candor Act," protects conversations between organizations, clinicians, patient, and families from legal discoverability and outlines criteria to guarantee that protection.
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.
Ameratunga R, Klonin H, Vaughan J, et al. BMJ. 2019;364:l706.
Recent high-profile incidents in the United States and the United Kingdom have fueled debate on the impact of criminalizing medical mistakes that result in patient harm. This article compares how the United Kingdom and New Zealand respond when patients experience unintentional health care–related harm. The authors emphasize the importance of focusing on resolution and learning to improve patient safety.
McMichael BJ, Van Horn L, Viscusi K. Stanford Law Rev. 2019;71:341-409.
Prior research has shown that patients prefer that errors and adverse events be fully disclosed to them by their providers. However, physicians may be hesitant to simultaneously express empathy out of fear that such an expression could be taken as an admission of fault that might result in litigation. As a result, 38 states and the District of Columbia passed apology laws, designed to make such apologetic statements inadmissible in court, but the effect of such laws on medical malpractice remains unknown. Using a dataset obtained from a large malpractice insurer, researchers analyzed claims against 90% of United States physicians by specialty over 8 years. They found that for physicians in nonsurgical fields, apology laws increased the risk of experiencing litigation as well as the average dollar amount paid to settle a claim. They did not find such an effect for surgeons. A past PSNet interview highlighted the challenges associated with disclosure and apology.
Morgan L, Benson D, McCulloch P. BMJ. 2019;364:l1037.
Investigations into medical mistakes that result in patient harm should be fair, complete, and consider the context of the event. This commentary examines investigation processes in the United Kingdom and highlights the importance of understanding how human factors contribute to error to help effectively assess each incident and support transparency and improvement.
Clarkson MD, Haskell H, Hemmelgarn C, et al. BMJ. 2019;364:l1233.
The term "second victim," coined by Dr. Albert Wu, has engendered mixed responses from patients and health care professionals. This commentary raises concerns that the term negates the sense of responsibility for errors that result in harm and advocates for abandoning it.