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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 - 5 of 5 Results
Kelley-Quon LI, Kirkpatrick MG, Ricca RL, et al. JAMA Surg. 2021;156:76.
Opioid misuse is an urgent patient safety issue, including postsurgical opioid misuse among pediatric patients. Based on the systematic review, a multidisciplinary group of health care and opioid stewardship experts proposes evidence-based opioid prescribing guidelines for children who need surgery. Endorsed guideline statements highlight three primary themes for perioperative pain management in children: (1) health care professionals must recognize the risks of pediatric opioid misuse, (2) use non-opioid pain relief, and (3) pre- and post-operative education for patients and families regarding pain management and safe opioid use.
Stulberg JJ, Huang R, Kreutzer L, et al. JAMA Surg. 2022;157:219-220.
This study examined variation in operative technical skills among patients undergoing colorectal and non-colorectal procedures and the association with patient outcomes. Higher technical skills were significantly associated with lower rates of complications, unplanned reoperations, and death or serious morbidity. The findings suggest that this skill variation accounts for more than 25% of the variation in patient outcomes.
Vandenberg AE, Kegler M, Hastings SN, et al. Int J Qual Health Care. 2020;32:470-476.
This article describes the implementation of the Enhancing Quality of Prescribing Practices for Older Adults in the Emergency Department (EQUIPPED) medication safety program at three academic medical centers. EQUIPPED is a multicomponent intervention intended to reduce potentially inappropriate prescribing among adults aged 65 and older who are discharged from the Emergency Department. The authors discuss lessons learned and provide insight which can inform implementation strategies at other institutions.
Engelhardt KE, Bilimoria KY, Johnson JK, et al. JAMA Surg. 2020;155:851-859.
This mixed-methods study analyzed data from a survey of general surgery residents and qualitative interviews with residents and program directors participating in the FIRST trial to assess preparedness for surgical residents. Results indicate the lack of preparedness was associated with inadequate exposure to resident responsibilities while in medical school, such as infrequent overnight calls or not completing a subinternship. Preparedness was associated with a nearly two-fold lower risk of experiencing burnout.
Mamede S, van Gog T, van den Berge K, et al. JAMA. 2010;304:1198-1203.
Diagnostic errors are frequently ascribed to cognitive errors on the part of clinicians. Prominent among these is availability bias, when clinicians choose the most available diagnosis—the first that comes to mind—when faced with a complex diagnostic scenario. In this Dutch study, internal medicine residents were presented with a series of diagnosed cases, then given cases with similar symptoms and asked to record their provisional diagnoses. The investigators did find evidence of availability bias, but also found that asking residents to reflect on their diagnostic process mitigated the effects of availability bias. Diagnostic errors have been termed the next frontier in patient safety, and an AHRQ WebM&M commentary discusses reflective practice and other methods of avoiding cognitive error in diagnosis.