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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 2768 Results
Zhong A, Amat MJ, Anderson TS, et al. JAMA Netw Open. 2023;6:e2343417.
Increased use of telehealth presents both benefits and potential threats to patient safety. In this study of 4,133 patients, researchers found that orders for colonoscopies or cardiac stress tests and dermatology referrals placed during telehealth visits were less likely to be completed within the designated timeframe compared to those ordered during in-person visits (43% vs. 58%). Not completing test or referrals within the recommended timeframe can increase the risk of delayed diagnoses and patient harm.
Simon LT, Van Buren T. NEJM Catal Innov Care Deliv. 2023;4.
Achieving zero preventable harm is an ongoing goal for healthcare organizations. This article describes one large, multistate community health system’s experience decreasing serious adverse events through implementation of high-reliability leadership, promoting human error prevention behaviors, and accelerating learning through a structured approach to cause analysis at both the individual and systems levels.

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

The application of evidence in real situations helps to embed innovation across systems and sustain care improvement. This collection of project highlight reports shares descriptions of implementation projects and research funded by AHRQ. Topics covered include patient engagement, health information technology, and healthcare facility design.
Schlesinger M, Grob R. Hastings Cent Rep. 2023;53:s22-s32.
Involvement in patient safety incidents can erode patient trust in their own physicians and the healthcare system. This article summarizes the estimated frequency of lost trust after patient safety incidents, external factors contributing to mistrust, and approaches to restoring trust after incidents.
Sittig DF, Yackel EE, Singh H. J Gen Intern Med. 2023;38:940-942.
Large-scale technology modifications can contribute to organizational disfunction. This commentary discusses five approaches to managing disruption associated with electronic health record modernization that establish cultural, functionality, staff, design, and monitoring conditions to reduce stress and the potential for patient harm during technology improvements.
Bushuven S, Bentele M, Bentele S, et al. J Med Syst. 2023;47:123.
ChatGPT has emerged as a potentially useful tool for clinicians and the public in obtaining heath advice and diagnosis. In this study, six iterations of 22 pediatric emergency vignettes were entered into ChatGPT (total of 132 scenarios) to assess diagnostic accuracy, emergency call advice, and validity of advice given. ChatGPT correctly recommended contacting medical professionals in all cases but only advised calling emergency medical services (EMS) or 911 in 12 of the 22 scenarios. The correct diagnosis was made in 94% of cases, consistent with other research into ChatGPT. Considerably more research is required before ChatGPT could be recommended for diagnostic advice.
List JM, Russell LE, Hausmann LRM, et al. Jt Comm J Qual Patient Saf. 2023;Epub Oct 10.
Unmet health-related social needs (HRSNs; e.g., housing instability, food insecurity) and healthcare disparities can place patients at increased risk for patient safety incidents and poor outcomes. This article describes how existing Veterans Health Administration (VHA) initiatives to address HRSNs and disparities are being leveraged to address new Joint Commission standards to improve health care equity.
Atlanta, GA: Centers for Disease Control and Prevention; November 2023.
This annual analysis explores rates of health care-associated infections (HAIs) reported in the United States. Data from 2022 revealed decreases in central line–associated bloodstream infections and other hospital-acquired infections while reporting little progress in other healthcare settings. The current report includes data from the National Healthcare Safety Network (NHSN).
Metz VE, Ray GT, Palzes V, et al. J Gen Intern Med. 2023;Epub Nov 6.
In response to the increasing opioid crisis, many medical associations, policy makers, and insurers have argued for dose reductions. However, when doses are reduced too quickly, patients may experience short- and long-term adverse events. Consistent with other studies, dose reductions higher than 30% were associated with higher odds of emergency department visits, opioid overdose, and all-cause mortality in the month following dose reduction.
Lucas P, Jesus É, Almeida S, et al. BMC Nurs. 2023;22:413.
A poor work environment can have a negative impact on quality and safety of patient care. This study of primary care nurses in Portugal shows that better work practice environments are associated with higher quality of care, patient safety, and safety culture. Nursing foundations for quality of care and collegial nurse-physician relations were the highest rated survey dimensions.
Cam H, Wennlöf B, Gillespie U, et al. BMC Health Serv Res. 2023;23:1211.
When patients are discharged from the hospital, they (and their informal caregivers) are given copious amounts of information that must also be communicated to their primary care provider. This qualitative study of primary care and hospital physicians, nurses, and pharmacists highlights several barriers to complete and effective communication between levels of care, particularly regarding geriatric medication safety. Barriers include the large number of complex patients and incongruent expectations of responsibility of primary and hospital providers. Support systems, such as electronic health records, can both enable and hinder communication.
Park J, Jeon H, Choi EK. J Adv Nurs. 2023;Epub Nov 10.
Digital health tools are increasingly used to support the delivery of safe healthcare. This scoping review characterized 13 articles exploring the use of digital interventions intended to support patient safety among pediatric patients and their parents. Interventions were commonly delivered through mobile applications, web-based technologies, computer kiosks, and electronic health records, and focused on patient safety event prevention and risk management.

Washington DC; VA Office of the Inspector General; October 31, 2023; Report no. 22-03599-07.

Disclosure failures detract from learning, appropriate incident examination, and safe care delivery. This report examined factors contributing to poor disclosure practices associated with the care of three patients. Lack of report submission, uninitiated root cause analysis, and inadequate documentation were process weaknesses highlighted by the review. 
Olazo K, Gallagher TH, Sarkar U. J Patient Saf. 2023;19:547-552.
Marginalized patients are more likely to experience adverse events and it is important to encourage effective disclosure to reinforce and reestablish trust between patients and providers. This qualitative study involving clinicians and patient safety professionals explored challenges responding to and disclosing errors involving historically marginalized patients. Participants identified multilevel challenges, including fragmentation of care and patient mistrust as well a desire for disclosure training and culturally appropriate disclosure toolkits to support effective error disclosure.
Lång K, Josefsson V, Larsson A-M, et al. Lancet Oncol. 2023;24:936-944.
Retrospective studies have shown artificial intelligence (AI) to be at least as accurate as radiologists in detecting breast cancer in screening mammograms. This prospective randomized trial similarly demonstrated that AI readings were as accurate as double readings by radiologists, but with a significantly reduced workload.
Winter SG, Sedgwick C, Wallace-Lacey A, et al. Clin Ther. 2023;45:928-934.
The VIONE (Vital, Important, Optional, Not indicated, and Every medication has an indication) tool is used to reduce polypharmacy and potentially inappropriate prescribing. This article provides an overview of VIONE implementation and dashboards used to track VIONE implementation and its impact on prescribing across over 130 Veterans Health Administration medical centers. Since implementation in 2016, VIONE has led to the discontinuation of over 1.6 million medication orders by more than 15,000 providers.
Arbaje AI, Greyson S, Keita Fakeye M, et al. J Patient Saf Risk Manag. 2023;28:201-207.
Older adult patients and family caregivers face numerous safety challenges when transitioning from the hospital to skilled home health (HH). This article describes how older adults and their family caregivers, HH frontline providers, HH leadership, and HH hospital-based transition coordinators, were engaged to identify best practices to implement the Hospital-to-Home Health Transition Quality (H3TQ) Index. This participatory co-design process identified ways patients, caregivers, and staff differ in how and when to administer the H3TQ Index, confirming the importance of engaging a wide range of stakeholders in design processes.

Galappatthy P, Mair A, Dhingra-Kumar N et al. Geneva, Switzerland: World Health Organization; 2023. ISBN 9789240058897.

Look-alike, sound-alike (LASA) medicines are known contributors to drug errors. This report discusses how name and label similarities degrade care, and the actions organizations and individual practitioners can take to mitigate the potential of LASA medication errors that cause harm. The authors discuss obstacles and enablers to implementing prevention strategies.
Liu Y, Jun H, Becker A, et al. J Prev Alz Dis. 2023;Epub Oct 24.
Persons with dementia are at increased risk for adverse events compared to those without dementia, highlighting the importance of a timely diagnosis. In this study, researchers estimate approximately 20% of primary care patients aged 65 and older are expected to have a diagnosis of mild cognitive impairment or dementia; however, only 8% have received such a diagnosis. Missed diagnosis prevents patients from receiving appropriate care, including newly FDA-approved medications to slow cognitive decline.

National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2023. ISBN: 9780309711937.

Maternal health care is rapidly emerging as a high-risk service that is vulnerable to communication, equity, and diagnostic challenges. This report examines the role of disparities in care across the maternal care continuum and strategies to drive diagnostic improvement such as care bundles, midwives, and health information technology. This publication is from a series of programs and resultant publications on improving diagnostic excellence.