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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 - 7 of 7 Results
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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.
Griffey RT, Schneider RM, Todorov AA. Ann Emerg Med. 2022;80:528-538.
Trigger tools are a novel method of detecting adverse events. This article describes the location, severity, omission/commission, and type of adverse events retrospectively detected using the computerized Emergency Department Trigger Tool (EDTT). Understanding the characteristics of prior adverse events can guide future quality and safety improvement efforts.
Park Y, Hu J, Singh M, et al. JAMA Netw Open. 2021;4:e213909.
Machine learning uses data and statistical methods to enhance risk prediction models and it has been promoted as a tool to improve healthcare safety. Using Medicaid claims data for a large cohort of White and Black pregnant females, this study evaluated approaches to reduce bias in clinical prediction algorithms for postpartum depression and mental health service utilization. The researchers found that a reweighing method in machine learning models was associated with a greater reduction in bias than excluding race from the prediction models. The authors suggest further examination of potentially biased data informing clinical prediction models and consideration of other methods to mitigate bias.
Mahajan P, Pai C-W, Cosby KS, et al. Diagnosis (Berl). 2021;8:340-346.
Diagnostic error is an ongoing patient safety challenge that can result in patient harm. This literature review identified a set of emergency department (ED)-focused electronic health record (EHR) triggers (e.g., death following ED visit, change in treating service after admission, unscheduled return to the ED resulting in admission) and non-EHR based signals (e.g., patient complaints, referral to risk management) with the potential to screen ED visits for diagnostic safety events.
Kern-Goldberger AR, Adelman J, Applebaum JR, et al. Obstet Gynecol. 2020;136:161-166.
This commentary presents two cases of near-miss wrong-patient order errors between mother-newborn pairs and discusses the unique threat the postpartum setting presents to electronic order safety. The article highlights opportunities for systems improvement.
Kandagatla P, Su W-TK, Adrianto I, et al. J Healthc Qual. 2021;43:101-109.
This study examined the association of inpatient harms (e.g., infections, medication-related harms) and 30-day readmissions through a retrospective analysis of adult surgical patients in a single heath system over a two year period. The authors found that the harms with the highest 30-day readmission rates were pressure ulcers (45%), central line-associated bloodstream infections (40%), Clostridium difficile infections (29%), international normalized ratio >5 for patients taking Warfarin (26%), and catheter-associated urinary tract infections. The authors also described the accuracy of a risk prediction model to identify high-risk patients for 30-day admissions.