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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 - 15 of 15 Results
Woods-Hill CZ, Colantuoni EA, Koontz DW, et al. JAMA Pediatr. 2022;176:690-698.
Stewardship interventions seek to optimize use of healthcare services, such as diagnostic tests or antibiotics. This article reports findings from a 14-site multidisciplinary collaborative evaluating pediatric intensive care unit (PICU) blood culture practices before and after implementation of a diagnostic stewardship intervention. Researchers found that rates of blood cultures, broad-spectrum antibiotic use, and central line-associated blood stream infections (CLABSI) were reduced postintervention.
Schefft M, Noda A, Godbout E. Curr Treat Options Pediatr. 2021;7:138-151.
Overuse of medical care represents a significant patient safety challenge. This review discusses the impacts of healthcare overuse and unnecessary care on patient safety, including contributions to avoidable adverse events, increasing risks for healthcare-acquired infections, and adverse psychological outcomes.
Huynh I, Rajendran T. BMJ Open Qual. 2021;10:e001363.
Unintentional therapeutic duplication can lead to life-threatening complications. As part of a quality improvement project on a surgical ward, staff were educated about the risks of therapeutic duplication and strategies to decrease it. After one month of education and reminders, the rate of therapeutic duplication decreased by more than half.

Saks MJ, Landsman S. Health Matrix: J Law-Med. 2020;30(1):25-84.

Defensive medicine behaviors seeking to avoid malpractice risk due to care omissions challenge patient safety and value narratives. This legal discussion examines factors driving defensive medicine and reveals complexities associated with the practice and reforms submitted to address them.    

Working Group on Medication Overload. Brookline, MA: Lown Institute; 2020.

Polypharmacy and medication overuse are known contributors to patient harm. This report outlines recommendations for combating medication overload. The recommendations include prescription review, issue awareness, point-of-care information access, training and industry influence reduction as tactics for improvement.
Horng S, Joseph JW, Calder S, et al. JAMA Netw Open. 2019;2:e1916499.
The adoption of electronic health record (EHR) systems has led to unanticipated patient safety concerns, such as duplicate orders for tests and medications. This study found that the implementation of a visual aid within the computerized provider order entry (CPOE) system to flag duplicate orders was associated with a 49% decrease in duplicate laboratory orders and a 40% decrease in radiology orders. The authors did not find a decrease in duplicate medication orders. A previous WebM&M commentary describes an adverse event related to duplicate medication orders.
Ganguli I. Washington Post. January 5, 2020.
Overdiagnosis and uncertainty can result in a range of care activities that contribute to financial, emotional and physical harms to patients and families. This story discusses unintended consequences of a medical test and offers suggestions for patients and clinician to reduce the potential for these harms without compromising care.
Ganguli I, Simpkin AL, Lupo C, et al. JAMA Netw Open. 2019;2:e1913325.
Cascades of care (or follow up) on incidental findings from diagnostic tests are common but are not always clinically meaningful. This study reports the results of a nationally representative group of physicians who were surveyed on their experiences with cascades. Almost all respondents had experienced cascades and many reported harms to patients and personal frustration and anxiety that may contribute to physician burnout.
Judson TJ, Press MJ, Detsky AS. Healthc (Amst). 2019;7:4-6.
Health care is working to provide high-value care and prevent overuse while ensuring patient safety. This commentary highlights the importance of educational initiatives, mentors, and use of clinical decision support to help clinicians determine what amount of care is appropriate for a given clinical situation.
Scott IA, Pillans PI, Barras M, et al. Ther Adv Drug Saf. 2018;9:559-573.
The prescribing of potentially inappropriate medications is a quality and safety concern. This narrative review found that information technologies equipped with decision support tools were modestly effective in reducing inappropriate prescribing of medications, more so in the hospital than the ambulatory environment.
Hoffmann TC, Del Mar C. JAMA Intern Med. 2015;175:274-286.
This systematic review found that patients generally overestimate benefits and underestimate harms related to tests and treatments. The topics studied included cancer, surgery, cardiovascular disease, fetal–maternal medicine, and medications. These findings suggest that unrealistic patient expectations may contribute to health care overuse.
Hoffman JR, Kanzaria HK. BMJ. 2014;349.
Lack of acceptance for human error and uncertainty have been known to contribute to overdiagnosis and overuse that may result in patient harm. This commentary explains why medical liability reform alone is not sufficient to address this issue. The authors suggest that both professionals and patients will need to adjust their expectations of failures in order to achieve behavior change.
Chicago, IL: American Hospital Association Physician Leadership Forum; July 2014.
Antimicrobial stewardship has been promoted as an element of patient safety. This toolkit provides resources for hospital administrators, clinicians, and patients to help prevent overuse of antibiotics, including a readiness assessment checklist, webinars, and frequently asked questions.