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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 21 Results

Adler-Milstein J, Aggarwal N, Ahmed M, et al. NAM Perspectives. Washington DC: National Academy of Medicine; 2022.

Artificial intelligence can support care through effective integration of computerized diagnostic decision support (DDS) systems. This report examines four foci for successful DDS use: why clinicians use it, what tools support it, how it is used, and the way it is accessed. Policies are introduced as a tactic to support unbiased and safe implementation of decision support systems.
Curated Libraries
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.
Curated Libraries
January 14, 2022
The medication-use process is highly complex with many steps and risk points for error, and those errors are a key target for improving safety. This Library reflects a curated selection of PSNet content focused on medication and drug errors. Included resources explore understanding harms from preventable medication use, medication safety...

Graber ML, Schrandt S. Evanston, IL:  Society to Improve Diagnosis in Medicine;  September 8, 2021. 

This report summarizes the results of a project that examined how the literature and various stakeholders consider challenges and opportunities for improving diagnosis during telemedicine interactions. Both areas of concern and potential were highlighted to engage researchers, educators, and clinicians in the implementation and use of telediagnosis that is safe and of high-value for patients and families.

Partnership for Health IT Patient Safety. Plymouth Meeting, PA: ECRI Institute; 2021.

Effective integration of health information systems supports decision making and treatment coordination across practice settings. This report examines how gaps in information sharing can affect behavioral health care. The authors discuss the potential for diagnostic improvement through information system connections between primary care and behavioral health programs.

Smith KM, Hunte HE, Graber ML. Rockville MD: Agency for Healthcare Research and Quality; August 2020. AHRQ Publication No. 20-0040-2-EF.

Telehealth is becoming a standard care mechanism due to COVID-19 concerns. This special issue brief discusses telediagnosis, shares system and associate factors affecting its reliability, challenges in adopting this mode of practice, and areas of research needed to fully understand its impact. This issue brief is part of a series on diagnostic safety.
Hochman M, Bourgoin A, Saluja S, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2019. AHRQ Publication No. 18(19)-0055-EF.
Programs are in place to address hospital discharge process gaps that contribute to readmissions. This report summarizes research on primary care perspectives on reducing readmissions. Interventions identified include automated alerting to primary care providers when patients are hospitalized and the patient-centered medical home model.
Washington, DC: United States Government Accountability Office; January 2019. Publication GAO-19-197.
Record matching problems can have serious clinical impacts on patients. This report explores how to optimize demographic data integrity to improve patient record matching, as identifying information is increasingly integrated into shared record keeping systems. The investigation determined strategies to improve matching such as implementing standard data formats and disseminating best practices.
Philadelphia, PA: Pew Charitable Trusts, American Medical Association, and Medstar Health; 2018.
Electronic health records both contribute to and detract from safe care. This report recommends best practices, test case criteria, and sample test cases to help developers and health care organizations identify and address electronic health record weaknesses and prevent patient harm.
Institute for Healthcare Improvement, National Patient Safety Foundation. Cambridge, MA: Institute for Healthcare Improvement; 2017.
Missed and delayed diagnoses can stem from problems in the outpatient referral process. The Institute for Healthcare Improvement convened an expert panel aimed at addressing safety vulnerabilities in the current referral process. The report delineates nine steps in the referral process, starting from the primary care provider ordering the referral and ending with communication of the treatment plan to patients and families. Recommendations to improve this process include interoperability between primary care and subspecialty electronic health records, standardizing handoffs between providers, clear standards of accountability for patient follow-up, and use of evidence-based communication methods like teach-back with patients and families. The report concludes that prioritizing the safety of the referral process is important to reduce diagnostic errors.
Zheng K, Ciemins EL, Lanham HJ, et al. Rockville, MD: Agency for Healthcare Research and Quality; July 2015. AHRQ Publication No. 15-0058-EF.
Ineffective implementation of health information technology (IT) can result in workarounds and other workflow changes that disrupt care delivery. This report examines how health IT implementation can affect clinician and staff workload in the ambulatory care environment, including increase interruptions and multitasking, and recommends workload considerations to enable staff to adapt to changes in practice.

Rockville, MD: Agency for Healthcare Research and Quality; September 2013. AHRQ Publication No. 13-0058-EF.  

This publication summarizes findings from 12 projects that explored how health information technology can enhance management and quality of care for patients with complex conditions in the ambulatory setting.
Doyle J. Melbourne, Australia: Victorian Auditor-General's Office; October 30, 2013.
Following the implementation of a large clinical information communication technology project, this report identified interoperability and usability failures and noted medication ordering and management as particularly vulnerable to errors.
Committee on the Role of Human Factors in Home Health Care. Washington, DC: National Research Council; 2011. ISBN: 9780309212366.
This report discusses the results of a 2009 AHRQ-funded workshop on how human factors can be applied to home-based care.
Carrier E, Yee T, Holtzwart RA. Washington, DC: National Institute for Health Care Reform; 2011. NIHCR Research Brief No. 3.
This report analyzes communication practices between emergency and primary care physicians and provides suggestions to improve and encourage meaningful communication.
Rockville, MD: Agency for Healthcare Research and Quality; July 2008. AHRQ Publication Nos. 080034 (1-4).
The 115 articles freely available in this latest issue of AHRQ's Advances in Patient Safety represent the state of the art in patient safety. Serving as an update and extension to the prior volume, the articles are grouped into four major content areas—assessment, culture and redesign, performance and tools, and technology and medication safety—and are freely available online through the link below.
Washington, DC: Office of the National Coordinator for Health Information Technology, US Department of Health and Human Services; 2007.
This report provides two example scenarios—inpatient medication reconciliation and medication management in ambulatory care—to explore how improved information exchange can support safe medication management.