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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 2014 Results

Meyer DB. Boca Raton, FL: Universal Publishers; 2022. ISBN:‎ 9781627344067

Individual commitment to patient safety can motivate change. This book highlights an advocacy action by a patient safety leader to generate awareness, engagement, and action using personal, professional, and patient stories of error.

Washington State Hospital Association. December 8, 2022, 4:00-5:00 PM (eastern).

Diagnostic error reduction is increasingly embraced as an element of patient safety strategic planning. This session will discuss the role of collaboratives as an approach to improvement and highlight opportunities for improving diagnosis on an organizational level.
Institute for Healthcare Improvement. March 8 - May 16, 2023.
Burnout among health care workers negatively affects system improvement. This webinar series will highlight strategies to establish a healthy work environment that strengthens teamwork, staff engagement, and resilience. Instructors include Dr. Donald Berwick and Derek Feeley.
Armstrong Institute for Patient Safety and Quality.
The comprehensive unit-based safety program (CUSP) approach emphasizes improving safety culture through a continuous process of reporting and learning from errors, improving teamwork, and engaging staff at all levels in safety efforts. Available on demand and live, this session covers how to utilize CUSP, including understanding and addressing challenges to implementation. The next live session will be held January 17, 2023.
AHA Team Training. January 12 - March 2, 2023.
The TeamSTEPPS program was developed to support effective communication and teamwork in health care. This online series will prepare participants to guide their organizations through implementation of the TeamSTEPPS program. It is designed for individuals that are new to TeamSTEPPS processes. 

National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2022. ISBN 9780309696333.

 

 

The care of older adult patients can be complicated due to comorbidities, bias and polypharmacy. This publication reports on a session that examined diagnostic challenges unique to the older adult population. The existing evidence base and strategies for the future are reviewed.
Wong J, Lee S-Y, Sarkar U, et al. Am J Health Syst Pharm. 2022;Epub Sep 27.
Medication errors in ambulatory care settings represent an ongoing patient safety challenge. This study characterizes ambulatory care adverse drug events reported to a large patient safety organization between May 2012 and October 2018. Anticoagulants, antibiotics, hypoglycemics, and opioids were the most commonly involved medication classes. Contributing factors included prescribing errors, failure to review clinical contraindications or drug-drug interactions, and lack of patient education or communication.
Institute for Safe Medication Practices. December 1-2, 2022.
This virtual workshop will explore tactics to ensure medication safety, including strategic planning, risk assessment, and Just Culture principles.
Liu G, Chimowitz H, Isbell LM. Diagnosis (Berl). 2022;9:295-305.
Clinician’s emotions can influence their decision making, particularly with “difficult” patients. This article describes the role affect takes in clinical reasoning, including diagnosis. Strategies to counter the impact of emotional affect, such as emotional intelligence education, are presented.
Soled KRS, Dimant OE, Tanguay J, et al. BMC Health Serv Res. 2022;22:1134.
Transgender and gender-diverse people can face discriminatory behaviors when accessing health care services. This qualitative study explored clinician perspectives with regard to practicing transgender health care. Findings indicate that stigma, gatekeeping, and knowledge deficits are barriers to high-quality care delivery but respondents also highlighted strategies for successful care delivery, including mentorship and use of a person-centered approach to care.

Rockville, MD: Agency for Healthcare Research and Quality; October 2022. AHRQ Publication no. 22(23)-0047-2-EF.

Delayed, wrong, and missed diagnoses are common challenges for patients, families, and clinicians, yet physicians rarely receive feedback on their actions to enhance diagnostic decision making. This publication provides clinicians with tools to assess and calibrate diagnostic performance in support of individual learning and improvement.
Arnaoutakis GJ, Ogami T, Aranda‐Michel E, et al. J Am Heart Assoc. 2022;11:e025026.
Missed diagnosis of aortic emergencies can result in patient death, therefore patients with presumed aortic syndromes may be transferred to aortic referral centers. Because interhospital transfers present their own risks, these researchers evaluated emergency transfers of patients who did not ultimately have a diagnosis of acute aortic dissection, intramural hematoma, penetrating aortic ulcer, thoracic aortic aneurysm, or aortic pseudoaneurysm. Approximately 11% of emergency transfers were misdiagnosed, secondary to imaging misinterpretation.
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.
Reeve J, Maden M, Hill R, et al. Health Technol Assess. 2022;26:1-148.
Deprescribing is a strategy to reduce potential harms associated with polypharmacy. This scoping review synthesized the evidence about how physicians and patients feel about deprescribing and how deprescribing can be done safely. Shared decision making was identified as an essential component for building trust in the process and for keeping it patient-centered.
WebM&M Case September 28, 2022

This case describes a 20-year-old woman was diagnosed with a pulmonary embolism and occlusive thrombus in the right brachial vein surrounding a  peripherally inserted central catheter (PICC) line (type, gauge, and length of time the PICC had been in place were not noted). The patient was discharged home but was not given any supplies for cleaning the PICC line, education regarding the signs of PICC line infection, or referral to home health services.

World Health Organization. September 17, 2022.
Patients, families, and providers around the world are affected by medical error. This annual event and its associated materials seek to raise awareness, motivate collaboration, and stimulate innovative work targeting a distinct patient safety theme. The 2022 theme is “Medication Safety” with the slogan “Medication without Harm". Explicit objectives of the effort include increasing awareness worldwide of the impact of medication errors and enabling a robust patient and family role in medication safety efforts.

Farnborough, UK: Healthcare Safety Investigation Branch; July 7, 2022.

Misuse of insulin pens contributes to never events associated with diabetic medication therapy in hospitalized patients. This investigation of an injurious insulin extraction workaround culminated in recommendations to improve insulin administration safety including the explicit use of pen devices to administer U-500 insulin.
Soto C, Dixon-Woods M, Tarrant C. Arch Dis Child. 2022;107:1038-1042.
Children with complex medical needs are vulnerable to patient safety threats. This qualitative study explored the perspectives of parents with children living at home with a central venous access device (CVAD). Parents highlight the persistent fear of central line-associated blood stream infections as well as the importance of maintaining a sense of normalcy for their children.

Washington DC; National Quality Forum and Anticoagulation Forum; 2022.

Warfarin and other anticoagulants are high-alert medications that, if errors occur in their use, can result in considerable harm. This document advocates that a stewardship approach be applied to anticoagulant therapy to reduce the risk of adverse events and discusses steps to implement and sustain a program to guide the safe, effective use of anticoagulants.
WebM&M Case August 31, 2022

A 49-year-old woman was referred by per primary care physician (PCP) to a gastroenterologist for recurrent bouts of abdominal pain, occasional vomiting, and diarrhea. Colonoscopy, esophagogastroduodenoscopy, and x-rays were interpreted as normal, and the patient was reassured that her symptoms should abate. The patient was seen by her PCP and visited the Emergency Department (ED) several times over the next six months. At each ED visit, the patient’s labs were normal and no imaging was performed.