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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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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.
Parker H, Frost J, Day J, et al. PLoS ONE. 2022;17:e0271454.
Prophylactic antimicrobials are frequently prescribed for surgical patients despite the risks of antimicrobial overuse (e.g., resistance). This review summarizes how and why antimicrobials continue to be prescribed in surgical settings despite evidence of overuse. Eight overarching concepts were identified: hierarchy; fear drives action; deprioritized; convention trumps evidence; complex judgments; discontinuity of care; team dynamics; and practice environment.
Krancevich NM, Belfer JJ, Draper HM, et al. Ann Pharmacother. 2022;56:52-59.
Prescribing opioids to opioid-naïve patients after hospital discharge may lead to chronic use. This study evaluated long-term opioid use among patients admitted directly to the ICU and who received intravenous opioids. While long-term opioid use was more common among patients who received an opioid prescription at discharge, the authors did not find a significant relationship between ICU opioid prescribing in opioid-naïve patients and long-term opioid use. The authors suggest future research focus on transitions from hospital to home or other post-acute sites to reduce inappropriate opioid use.
Horberg MA, Nassery N, Rubenstein KB, et al. Diagnosis (Berl). 2021;8:479-488.
Missed or delayed diagnosis of sepsis can lead to serious patient harm. This study used a Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) “look-forward” analysis to measure potential misdiagnosis of sepsis in patients discharged from the emergency department (ED) with treat-and-release fluid and electrolyte disorders (FED) or altered mental status (AMS). FED and AMS were associated with a spike in sepsis hospitalizations in the 7-day period following the ED visit. The authors suggest SPADE could be used to compare sepsis diagnostic performance across institutions and regions; develop interventions for targeted subgroups; and update early warning systems for sepsis diagnosis.
Han D, Khadka A, McConnell M, et al. JAMA Netw Open. 2020;3:e2024589.
Unexpected death or serious disability of a newborn is considered a never event. A cross-sectional analysis including over 5 million births between 2011 and 2017 in the United States found unexpected newborn death was associated with a significant increase in use of procedures to avert or mitigate fetal distress and newborn complications (e.g., cesarean delivery, antibiotic use for suspected sepsis). These findings could reflect increased caution among clinicals or indicate more proactive attempts to identify and address potential complications.  
Westman M, Takala R, Rahi M, et al. World Neurosurg. 2019.
Checklists have been shown to improve patient safety in various surgical specialties but this systematic review found that evidence of their impact in neurosurgery is still limited given emerging technologies such as robotics and artificial intelligence. Studies with larger neurosurgical patient populations, as well as in relation to robotic neurosurgery, are needed to understand the impact of checklists in neurosurgery.
Kozhimannil KB. Health Aff (Millwood). 2018;37:1901-1904.
Maternal harm is a sentinel event that is gaining increased attention in both policy and clinical environments. In this commentary, the author relates her family history of maternal morbidity and mortality and advocates for enhancements in collecting data on maternal health outcomes, access to care, understanding of racial disparities, accountability, and listening to patients and families who have been impacted by unsafe maternal care.
Chrouser KL, Xu J, Hallbeck S, et al. Am J Surg. 2018;216:573-584.
Stressful clinician interactions can diminish the teamwork required to support safe care. This review describes a framework for guiding understanding of how behavioral and emotional responses can affect team behavior, performance, and patient outcomes in the surgical setting. The authors recommend areas of research required to fully understand the phenomenon.
Bergl PA, Nanchal RS, Singh H. Ann Am Thorac Soc. 2018;15:903-907.
Elements of critical care can influence the reliability of diagnosis, teamwork, and care delivery. This commentary recommends areas for research to reduce diagnostic error in the intensive care unit. The authors highlight the need for intensivist involvement to define distinct roles and actions in their specialty for diagnostic improvement.
Law AC, Roche S, Reichheld A, et al. Jt Comm J Qual Patient Saf. 2019;45:276-284.
Emotional and psychological harm are understudied but common preventable adverse events. Overt disrespect from health care providers and the lasting psychological impact of safety hazards both contribute to emotional harm. This large, prospective study explored emotional harm among 1559 family members of intensive care unit patients at a hospital in Boston, Massachusetts. About 22% of family members reported inadequate respect toward either themselves or the patient, and more than half of respondents perceived a lack of control over their loved one's care. Inadequate respect and lack of control were strongly correlated with overall satisfaction with care. A WebM&M commentary discussed the utility of family-centered care to preventing harm in the intensive care unit.