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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 1280 Results
Kramer DB, Yeh RW. JAMA. 2023;329:136-143.
The Food and Drug Administration (FDA) plays an important role in ensuring the safety of medical devices. In this cross-sectional study, researchers identified a high risk of future Class 1 FDA recall (the most serious recall designation, indicating serious risks to patient safety) among previously authorized devices (predicates) with prior Class 1 recalls.
Barrett AK, Sandbrink F, Mardian A, et al. J Gen Intern Med. 2022;37:4037-4046.
Opioid medication use is associated with an increased risk of adverse events; however research has shown sudden discontinuation of opioids is also associated with adverse events such as withdrawal and hospitalization. This before and after study evaluated the impact of the VA’s Opioid Safety Initiative (OSI) on characteristics and prescribing practices. Results indicate that length of tapering period increased, and mortality risk decreased following OSI implementation.

Ramachandran V. Kaiser Health News. January 6, 2023.

Inadequate equipment and personnel training degrade the reliability of individuals to provide safe care in an emergency. This article discusses inconsistent preparedness throughout commercial aviation to support care during an in-flight medical situation; it suggests federal oversight of medical kits may help to ensure their completeness and improve the potential for safety should care be required.
Doctor JN, Stewart E, Lev R, et al. JAMA Netw Open. 2023;6:e2249877.
Research has shown that prescribers who are notified of a patient’s fatal opioid overdose will decrease milligram morphine equivalents (MME) up to 3 months following notification as compared to prescribers who are not notified. This article reports on the same cohort’s prescribing behavior at 4-12 months. Among prescribers who received notification, total weekly MME continued to decrease more than the control group during the 4-12 month period.
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.
Svedahl ER, Pape K, Austad B, et al. BMJ Qual Saf. 2022;Epub Dec 15.
Inappropriate referrals and unnecessary hospital admissions are ongoing patient safety problems. This cohort study set in Norway examined the impact of emergency physician referral thresholds from out-of-hours services on patient outcomes.  
Portland, OR: Oregon Patient Safety Commission.
This site provides data and analysis from two Oregon Patient Safety Commission patient safety initiatives: the Patient Safety Reporting Program (PSRP) and Early Discussion and Resolution (EDR) effort. The review of 2021 PSRP data discusses the impact of the state adverse event reporting program and upcoming initiative to examine how organizational safety effort prioritization affects care in Oregon. The 2022 EDR analysis discusses the uptake of the program to generate conversations with patients and providers after a patient safety incident occurred.
Varady NH, Worsham CM, Chen AF, et al. Proc Natl Acad Sci USA. 2022;119:e2210226119.
Safe prescribing dictates that prescriptions should only be written for the patients who are intended to use the prescribed medications. Using claims data, this analysis identified a high rate of opioid prescriptions written for and filled by the spouses of patients undergoing outpatient surgery (who may be unable to fill prescriptions themselves after surgery). Findings suggest intentional, clinically inappropriate prescribing of opioids.
Apathy NC, Howe JL, Krevat SA, et al. JAMA Health Forum. 2022;3:e223872.
Electronic Health Record (EHR) systems are required to meet meaningful use and certification standards to receive incentive payments from the US Department of Health and Human Services (HHS). This study identified six settlements reached between EHR vendors and the Department of Justice for misconduct related to certification of meaningful use. Certification of EHR systems that don’t meet HHS meaningful use requirements may have implications for patient safety.

Federal Office of Public Health. 2m2c Convention Centre, Montreux, Switzerland, February 23-24, 2023.

Medical errors continue to cause harm worldwide despite the planning and efforts to reduce them. This bi-yearly session will feature topics exploring the theme of “Less Harm, Better Care – from Resolution to Implementation.” It will cover weaknesses in improvement initiative implementation surfaced by the COVID-19 pandemic and offer approaches for addressing unsustainable program launches and implementation practices.
Temkin-Greener H, Mao Y, McGarry B, et al. J Am Med Dir Assoc. 2022;23:1997-2002.e3.
Long-term care facilities can struggle with establishing a safety culture. Researchers in this study adapted the AHRQ Surveys on Patient Safety Culture™ (SOPS®) Nursing Home Survey to assess patient safety culture in assisted living facilities. Findings show that direct care workers had significantly worse perceptions of patient safety culture (including nonpunitive responses to mistakes, management support for resident safety, and teamwork) compared to administrators. A PSNet perspective discusses how to change safety culture.
Essex R, Weldon SM, Thompson T, et al. Health Serv Res. 2022;57:1218-1234.
A systematic review in early 2022 revealed healthcare worker strikes may negatively impact patient safety but also result in long-term benefits. This review by the same authors explores the impact of strikes on in-hospital and population mortality. None of the 11 studies examining in-hospital mortality reported a significant difference between mortality during the strike compared to the control period. Similarly, there was no difference in population mortality.

Baker MB. Harv Civ Rights-Civil Lib Law Rev. 2022: 57(Summer):321-360.

Women of color are at risk of bias that reduces the safety of their medical care experience. This article discusses the history of racism in health care, low quality maternal care of Black women, and barriers to safe care for that patient population. The piece also discusses challenges to effective legal response for Black women who experience poor care and strategies to address those barriers.
Sephien A, Reljic T, Jordan J, et al. Med Educ. 2022;Epub Oct 1.
The Accreditation Council for Graduate Medical Education (ACGME) includes work hour restrictions in its Common Program Requirements. The focus of this review is the impact of resident work hour restrictions on patient- and resident-level outcomes. Shorter shift hours were associated with some improved resident outcomes and but no association with patient outcomes.
Sutherland A, Jones MD, Howlett M, et al. Drug Saf. 2022;45:881-889.
Intravenous (IV) medication smart pumps can improve medication administration, but usability issues can compromise safety. This article outlines strategic recommendations regarding the implementation of smart pump technology to improve patient safety. Recommendations include standardization of infusion concentrations, improving drug libraries using a human-centered approach, and increasing stakeholder engagement.
Ünal A, Seren Intepeler Ş. J Patient Saf. 2022;18:e1102-e1108.
Increasing patient safety event reporting is an ongoing priority. This article summarizes the trends in medical error reporting and reporting system research from 1970 to 2021. While the number of publications increased annually, researchers observed a lack of cross-country collaboration on studies evaluating error reporting systems.

Jean-Pierre P. Boston U Law Rev. 2022; 102(1):327-392.

Bias and discrimination are receiving overdue attention as primary barriers to patient safety. This article discusses medical error, ineffective response to error, social trust and health care, state apology laws and the role of communication and resolution programs (CRP) to reduce additional harms associated with medical errors, all in the context of marginalized populations.