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 192 Results

Diagnosing fast and slow: cognitive bias in obstetrics.

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Atallah F, Gomes C, Minkoff H. Obstet Gynecol. 2023;142:727-732.

Researchers describe two types of decision making in medicine - fast (intuitive) and slow (analytical). While both types are subject to bias, this paper describes how cognitive biases in fast thinking, such as anchoring or framing, as well as racial or moral bias, can result in obstetrical misdiagnosis. Ten steps to mitigate these cognitive biases are laid out.

Uncovering the shocking dangers of misdiagnosis.

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Graedon T. People’s Pharmacy. Show 1355. September 8, 2023.

Misdiagnosis continues to impact the safety of health care. This podcast with David Newman-Toker discusses foundational issues that detract from diagnostic safety and examines how teamwork, training, technology, tuning can make the process more reliable. Strategies for patients to play a role in their diagnostic process are also discussed.

Handling polypharmacy--a qualitative study using focus group interviews with older patients, their relatives, and healthcare professionals.

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Mikkelsen TH, Søndergaard J, Kjaer NK, et al. BMC Geriatr. 2023;23:477.

Older adults taking 5 or more medications daily (i.e., polypharmacy) face numerous challenges to taking them safely. In this study, patients, caregivers, and clinicians describe methods to taking medications safely, difficulties they face, and ways prescribers and pharmacists can assist patients. Medication reviews, a common strategy to ensure safe polypharmacy, were requested by patients to clear up confusion around generics, timing, limitations, and side effects.

Vital signs: maternity care experiences — United States, April 2023.

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Mohamoud YA, Cassidy E, Fuchs E, et al. MMWR Morb Mortal Wkly Rep. 2023;72:961–967.

Previous research has found that women often experience mistreatment and discrimination during maternity care. This CDC analysis of survey data for 2,402 respondents found that approximately one in five women experienced at least one type of mistreatment during maternity care (i.e., being ignored or refused, being shouted at or scolded, having their physical privacy violated). Nearly 29% of respondents reported experiencing at least one form of discrimination during their maternity care (i.e., age-, weight-, income-, or race/ethnicity-based discrimination).

Dangers and deaths around black pregnancies seen as a ‘completely preventable’ health crisis.

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West S. KFF Health News. August 24, 2023.

The challenge of unsafe maternal care is gaining deserved attention across the system spectrum. This article discusses the preventative nature of many barriers to safe care Black mothers face including lack of health insurance, limited access to prenatal care and disrespect for concerns during care encounters.

Patient Safety Executive Development Program.

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Institute for Healthcare Improvement. Boston, MA and online. August 30-October 13, 2023.

Organization executives influence the success of patient safety improvement. This hybrid workshop will highlight how leaders can use assessments, planning, and evidence to improve the safety culture at their organizations.

The Pursuing Excellence Collaborative: engaging first-year residents and fellows in patient safety event investigations.

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Paull DE, Newton RC, Tess AV, et al. J Patient Saf. 2023;19:484-492.

Previous research suggests that residents may underutilize adverse event reporting tools. This article describes an 18-month clinical learning collaborative among 16 sites intended to increase resident and fellow participation in patient safety event investigations. Researchers found the collaborative increased participation in event investigation and improved the quality of the investigation.

Covering Health: Patient Safety.

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HealthJournalism.org. Columbia, MO: Association of Health Care Journalists; 2010-2023.

The role media plays in raising awareness of patient safety issues in a timely and appropriate manner is consequential. This series instructs writers to communicate on medical error and quality topics in a high-quality professional style with discernment of the content being reported. Series contributions include discussions on medical error statistics and outpatient surgery rankings.

Only 1 in 5 people with opioid addiction get the medications to treat it, study finds.

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Mann B. Health Shots. National Public Radio. August 7, 2023.

Stigma against behavioral health conditions is known to affect the quality of care relationships and therapeutic actions. This news article discusses the limited use of methadone and other medications as strategies to assist in the care and recovery of opioid use disorder patients.

Toolkits To Reduce Hypertension in Pregnancy and Obstetric Hemorrhage.

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Rockville, MD: Agency for Healthcare Research and Quality; July 2023.

Obstetric hemorrhage and severe high blood pressure during pregnancy are leading known causes of preventable maternal harms in the United States. The AHRQ Safety Program for Perinatal Care, Phase 2 developed toolkits consisting of case scenarios, slides, and facilitators guides to work in tandem to address these threats to maternal safety. The materials inform training opportunities to improve the safety culture of labor and delivery units and decrease maternal and neonatal adverse events that result from poor communication and system failures.

Reimagining Healthcare Teams: Leveraging the Patient-Clinician-AI Triad To Improve Diagnostic Safety.

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James C, Singh K, Valley TS, et al. Rockville, MD; Agency for Healthcare Research and Quality; July 2023. AHRQ Publication No. 23-0040-4-EF.

As artificial intelligence (AI) and machine learning (ML) become established in health care, it is critical for clinicians and patients to effectively collaborate to use AI safely. This Issue Brief adds to a series of diagnostic-focused reports and presents a framework to guide patients and clinicians on working as team members when using AI and ML to make diagnostic decisions.

Advancing Diagnostic Excellence in Maternal Health Care.

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Board on Health Care Services, National Academies of Science, Engineering, and Medicine. Arnold and Mabel Beckman Center, Irvine, CA. July 27, 2023.

Misdiagnosis during pregnancy can have tragic results for both the pregnant person and infant. This free workshop will discuss current challenges in maternal diagnostic excellence, identifications of knowledge gaps, and strategies to decrease maternal disparities. The workshop is open to the public can be attended in-person or virtually.

Health literacy and systemic racism—using clear communication to reduce health care inequities.

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Coleman C, Birk S, DeVoe J. JAMA Intern Med. 2023;183:753-754.

Low personal health literacy is associated with increased post-discharge adverse events and health inequities. This commentary describes organizational strategies to improve health literacy, including elimination of jargon in written and spoken communications and assessment of health professionals’ patient-centered communication tools.

A scoping review of legibility of hand-written prescriptions and drug-orders: the writing on the wall.

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Ariaga A, Balzan D, Falzon S, et al. Expert Rev Clin Pharmacol. 2023;16:617-621.

Illegible prescriptions can cause pharmacists to dispense incorrect medications resulting in patient harm. This review identified 15 studies on illegible prescriptions. Most of the studies were more than 10 years old and the authors acknowledge the advent of computerized provider order entry (CPOE) has reduced incidence of illegible prescriptions. However, CPOE relies on highly functional information technology systems which may be cost-prohibitive for some countries.

‘I felt like I was dying’: how women with postpartum depression fall through the cracks of U.S. health care.

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Gammon K. STAT. June 26, 2023.

The maternal mental health crisis results in harm to mothers and their families. This article discusses systemic issues that impact the safe psychological care of mothers from pregnancy through the years of caring for toddlers. Lack of timely diagnosis is a major consideration discussed.

Introducing second-year medical students to diagnostic reasoning concepts and skills via a virtual curriculum.

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Chang C, Varghese N, Machiorlatti M. Diagnosis (Berl). 2023;10:105-109.

Clerkship directors indicate clinical and diagnostic reasoning education should be included in medical school curricula, but up to half of programs do not offer it. This article describes the development, implementation, and evaluation of a diagnostic reasoning virtual training for pre-clinical medical students. Students reported increased confidence and understanding of diagnostic reasoning.

Context matters: toward a multilevel perspective on context in clinical reasoning and error.

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Choi JJ, Durning SJ. Diagnosis (Berl). 2023;10:89-95.

Context (e.g., patient characteristics, setting) can influence clinical reasoning and increase the risk for diagnostic errors. This article explores the ways in which individual-, team-, and system-level contextual factors impact reasoning, clinician performance and risk of error. The authors propose a multilevel framework to better understand how contextual factors impact clinical reasoning.

After Roe: Challenges in the Provision of Lifesaving Care.

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National Academies of Health.

Delay in access to obstetric care hinders safe treatment for patients experiencing pregnancy complications. This webinar discussed a range of factors affected by abortion restrictions and reviewed options to ensuring safety given legal and other structural impediments. A written brief is forthcoming.

What Happened to Patient Safety.

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Sheridan S. Turn on the Lights. Institute for Healthcare Improvement. May 2023

Patient engagement is an important component in patient safety. This episode from the Turn on the Lights podcast (hosted by Institute for Healthcare Improvement leaders Don Berwick, MD and Kedar Mate, MD) features a discussion with Sue Sheridan from Patients for Patient Safety US about the importance of involving patients and patient perspectives in the development of patient safety solutions.

Racial inequality in receipt of medications for opioid use disorder.

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Barnett ML, Meara E, Lewinson T, et al. New Engl J Med. 2023;388:1779-1789.

Best practices for treating patients with opioid use disorder (OUD) include prescribing medications to treat OUD (naltrexone, naloxone, or buprenorphine) and limiting prescriptions of high-risk medications (opioid analgesics and benzodiazepines). This study of more than 23,000 patients with an index event related to OUD sought to determine racial and ethnic differences in safe prescribing. White patients were significantly more likely to receive buprenorphine and less likely to receive high-risk medications than Black or Hispanic patients in the 180 days after the index event. This difference persisted over the four-year study period.

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