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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 855 Results
Wells JM, Walker VP. Health Promot Pract. 2023:152483992211451.
Addressing racism in healthcare is a patient safety priority. This article discusses how an active presence by hospital threat management systems (e.g., hospital-employed security, local law enforcement personnel) in pediatric emergency departments (EDs) can help ensure patient safety but also contributes to unsafe care due to racial stereotypes and threat perception among minority patients and caregivers. The authors outline patient-centered strategies at the individual-, intra-organizational-, and extra-organizational levels for responding to disruptive and violent events.
Reyes AM, Royan R, Feinglass J, et al. JAMA Surg. 2023;Epub Jan 18.
Delays in diagnosis and treatment can lead to poor outcomes. In this population-based retrospective longitudinal study using inpatient and emergency department discharge data from four states, researchers found that non-Hispanic Black patients were at higher risk for delayed diagnosis of appendicitis compared to White patients. This increased risk for delayed diagnosis translated into higher risks for postoperative 30-day readmission rates. The researchers found that this risk was mitigated when Black patients received care at hospitals serving a more diverse patient population.
WebM&M Case February 1, 2023

This WebM&M highlights two cases of hospital-acquired diabetic ketoacidosis (DKA) in patients with type 1 diabetes. The commentary discusses the role of the inpatient glycemic team to assist with diabetes management, the importance of medication reconciliation in the emergency department (ED) for high-risk patients on insulin, and strategies to empower patients and caregivers to speak up about medication safety.

Huff NR, Liu G, Chimowitz H, et al. Int J Nurs Stud Adv. 2022;5:100111.
Negative emotions can adversely impact perception of both patient safety and personal risks. In this study, emergency nurses were surveyed about their emotions (e.g., afraid, calm), emotional suppression and reappraisal behaviors, and perceived risk of personal and patient safety during the COVID-19 pandemic. Nurses reported feeling both positive and negative emotions, but only negative emotions were significantly associated with greater perception of risk.
Agarwal AK, Sagan C, Gonzales R, et al. J Am Coll Emerg Physicians Open. 2022;3:e12870.
Black patients who report experiencing racism in healthcare report poorer quality of care. In this text-message based study, Black and White patients discharged from the emergency department (ED) were asked about their overall quality of care and whether they perceived an impact of their race on their care. While Black patients reported high overall quality of care, 10% believed their race negatively impacted their care. The authors highlight the importance of asking about the impact of race on care to identify and reduce potential disparities.

Abelson R. New York Times. December 15, 2022.

Emergency department safety is challenged by factors such as production pressure, burnout, and overcrowding. This news article provides context for the 2022 AHRQ report Diagnostic Errors in the Emergency Department: A Systematic Review from the Johns Hopkins Medicine Evidence-based Practice Center (EPC) which synthesized the number of patients harmed while seeking emergency care.
Bloomer A, Wally M, Bailey G, et al. Geriatr Orthop Surg Rehabil. 2022;13:215145932211256.
Opioid use by older adults increases the risk of falls. This study examined electronic health record data to determine the proportion of older adults presenting to the emergency room or urgent care due to a fall who receive an opioid prescription, particularly those with at least one risk factor for misuse. Nearly one third of patients received a prescription for an opioid and/or benzodiazepine, and 11% had at least one risk factor for misuse.
Erstad BL, Romero AV, Barletta JF. Am J Health Syst Pharm. 2023;80:87-91.
Weight-based dosing is vulnerable to error due to inaccurate estimation of body weight, use of metric vs. non-metric units, or patients being underweight or overweight. This commentary suggests strategies for reducing weight- and size-based dosing errors including reduction in reliance on estimated body weight, standardizing descriptor (e.g., body mass index), limiting options in the electronic health record (EHR), and integrating complex calculations into the EHR.

Newman-Toker DE, Peterson SM, Badihian S, et al. Rockville, MD: Agency for Healthcare Research and Quality; December 2022. AHRQ Publication No. 22(23)-EHC043.

Although diagnostic accuracy in the emergency department (ED) is high, diagnostic errors still occur. This evidence review estimated that 1 in 18 ED patients receive an incorrect diagnosis, which translates to 7.4 million patients misdiagnosed every year (or 5.7% of all ED visits annually). Five conditions were found to be most vulnerable to misdiagnosis: stroke, heart attack, aortic aneurysm/ dissection, spinal cord injury and blood clots. The evidence review identified variation in diagnostic error rates across demographic groups; female sex and non-White race were often associated with increased risk for diagnostic errors. Serious misdiagnosis-related harms were often associated with clinician bedside judgement and other cognitive failures. 
Feldman N, Volz N, Snow T, et al. J Patient Saf Risk Manag. 2022;27:229-233.
Research with medical and surgical residents has shown they are frequently reluctant to speak up about safety and unprofessional behavior they observe. This study asked emergency medicine residents about their speaking up behaviors. Using the Speaking Up Climate (SUC)-Safe and SUC-Prof surveys, residents reported generally neutral responses to speaking up, more favorable than their medical and surgical counterparts. In line with other studies, residents were more likely to speak up about patient safety than about unprofessional behaviors.
Hoot NR, Barbosa TJ, Chan HK, et al. J Am Coll Emerg Physicians Open. 2022;3:e12849.
Previous research has suggested that increases in physician workloads can threaten patient safety. This retrospective study found that medical errors are higher among emergency medicine physicians with lower productivity, as measured by the number of patients seen per hour.
Rose SC, Ashari NA, Davies JM, et al. CJEM. 2022;24:695-701.
Debriefing is used to enhance individual and team communication and to facilitate real-time learning opportunities after a critical event. This study evaluated a charge nurse-facilitated clinical debriefing program used in Emergency Departments (EDs) in Alberta, Canada. Qualitative analyses identified several themes underscoring the impact of the debriefing program – the impacts on clinical practice and patient care, impacts on psychological safety and teamwork, stress management, and the emotional acknowledgement after critical events – and barriers to debriefing.
Ostrovsky D, Novack V, Smulowitz PB, et al. JAMA Network Open. 2022;5:e2241461.
Previous research has found that fear of malpractice can influence medical decision-making. This survey of emergency department attending physicians and advanced practice clinicians in Massachusetts found that fear of harming patients played a larger role in medical decision-making than fear of legal action.
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.

Sibbald M, Abdulla B, Keuhl A, et al. JMIR Hum Factors. 2022;9:e39234.
Electronic differential diagnostic support (EDS) are decision aids that suggest one or more differential diagnoses based on clinical data entered by the clinician. The generated list may prompt the clinician to consider additional diagnoses. This study simulated the use of one EDS, Isabel, in the emergency department to identify barriers and supports to its effectiveness. Four themes emerged. Notably, some physicians thought the EDS-generated differentials could reduce bias while others suggested it could introduce bias.
Patient Safety Innovation November 16, 2022

Appropriate follow-up of incidental abnormal radiological findings is an ongoing patient safety challenge. Inadequate follow-up can contribute to missed or delayed diagnosis, potentially resulting in poorer patient outcomes. This study describes implementation of an electronic health record-based referral system for patients with incidental radiologic finding in the emergency room. 

WebM&M Case November 16, 2022

A 61-year-old women with a mechanical aortic valve on chronic warfarin therapy was referred to the emergency department (ED) for urgent computed tomography (CT) imaging of the right leg to rule out an arterial clot. CT imaging revealed two arterial thromboses the right lower extremity and an echocardiogram revealed a thrombus near the prosthetic heart valve. The attending physician ordered discontinuation of warfarin and initiation of a heparin drip.