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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 122 Results
Farzandipour M, Nabovati E, Sharif R. J Telemed Telecare. 2023;Epub Jan 23.
Remote triage allows patients to receive guidance about whether to seek care and, if required, what level of care. This review of remote triage focuses exclusively on tele-triage studies conducted during the COVID-19 pandemic. The studies reported on five broad outcome categories (access to care, triage rates, patient safety, post-triage clinical outcomes, and patient satisfaction) with highly positive outcomes.
Healy A, Davidson C, Allbert J, et al. Am J Obstet Gynecol. 2022;Epub Dec 5.
The demand for, and acceptance of, telemedicine solutions to provide services has grown substantially in recent years as safety profiles for the services are being defined. This guideline examines its use in pregnancy-related care, discusses the benefits and suggests actions to ensure patient safety during these encounters such as development of appropriate metrics and methods for vital-sign monitoring.
Gleeson LL, Clyne B, Barlow JW, et al. Int J Pharm Pract. 2023;30:495-506.
Remote delivery of care, such as telehealth and e-prescribing, increased sharply at the beginning of the COVID-19 pandemic. This rapid review was conducted to determine the types and frequency of medication safety incidents associated with remote delivery of primary care prior to the pandemic. Fifteen articles were identified covering medication safety and e-prescribing; none of these studies associated medication safety and telehealth.

Agency for Healthcare Research and Quality.

Telemedicine efforts harbor both risk and reward to patients and providers. The AHRQ Safety Program for Telemedicine is a national effort to develop and implement a bundle of evidence-based interventions designed to improve telemedicine care in two settings—the cancer diagnostic process and antibiotic use. To test the bundle of interventions, the program will involve two cohorts of healthcare professionals who utilize telemedicine as a care delivery model. It is an 18-month program, beginning in June 2023, that seeks to improve the cancer diagnostic process for patients who receive some or all of their care through telemedicine. Recruitment webinars start in late January and run through early May 2023; the antibiotic use cohort will begin recruitment in December 2023. 
Patient Safety Primer December 14, 2022

The rapid expansion of telehealth and the variation in implementation of new models of care into medical practice has resulted in emerging concerns regarding patient safety. This primer summarizes these concerns – including diagnostic errors, medication errors, and health equity considerations – as well as telehealth implementation strategies to enhance patient safety.

Darley S, Coulson T, Peek N, et al. J Med Internet Res. 2022;24:e37436.
Electronic communication between patients and clinicians has been increasing, with a rapid expansion of its use during the COVID-19 pandemic. This systematic review examined the types of online consultation available to patients in primary care and their impact on safety. Results reveal both positive and negative impacts, and the authors make recommendations to mitigate the negative impacts.
WebM&M Case August 31, 2022

A 2-year-old girl presented to her pediatrician with a cough, runny nose, low grade fever and fatigue; a nasal swab for SARS-CoV-2 and influenza was negative and lung sounds were clear. The patient developed a fever and labored breathing and was taken to the Emergency Department (ED) before being admitted to the hospital. She developed respiratory distress and clinically worsened over time until she developed respiratory failure requiring air transportation to the pediatric intensive care unit at a children’s hospital.

NIHCM Foundation. Washington DC: National Institute for Health Care Management. August 2, 2022.

Preventable maternal morbidity is an ongoing challenge in the United States. This infographic shares general data and statistics that demonstrate the presence of racial disparities in maternal care that are linked to structural racism. The resource highlights several avenues for improvement such as diversification of the perinatal staffing and increased access to telehealth.
De Micco F, Fineschi V, Banfi G, et al. Front Med (Lausanne). 2022;9:901788.
The COVID-19 pandemic led to a significant increase in the use of telehealth. This article summarizes several challenges that need to be addressed (e.g., human factors, provider-patient relationships, structural, and technological factors) in order to support continuous improvement in the safety of health care delivered via telemedicine.
Powell ES, Bond WF, Barker LT, et al. J Patient Saf. 2022;18:302-309.
Telehealth is increasingly used to connect rural hospitals with specialists in other areas and can improve patient outcomes. This study found that in situ simulation training in rural emergency departments resulted in small increases in the use of telemedicine for patients presenting with sepsis and led to improvements in sepsis process care outcomes.

ECRI. Plymouth Meeting, PA. March 2022.

The global COVID-19 pandemic has exacerbated patient safety concerns. ECRI presents the top ten patient concerns for 2022, including staffing challenges, human factors in telehealth, and supply chain disruptions.
Shah RK, Reinhart R, Cronin J. Otolaryngol Clin North Am. 2022;55:105-113.
Experts have advocated the importance of establishing the business case for safety. This article summarizes approaches to establishing the business case for safety through the use of telehealth case-based vignettes as examples. The authors discuss challenges for establishing a business case for safety and future directions.
Wieringa S, Neves AL, Rushforth A, et al. BMJ Qual Saf. 2022;Epub Mar 8.
The COVID-19 pandemic dramatically increased the use of telehealth, including remote primary care triage and assessment. This qualitative study explored patients’ and clinicians’ experiences managing suspected COVID-19 during remote triage and assessment. Findings highlight the need to strengthen organizational resilience, develop and implement triage decision support tools, and address vulnerable and unsupported groups (e.g., the elderly, vulnerable and homebound patients).
Mullur J, Chen Y-C, Wickner PG, et al. J Patient Saf. 2022;18:e431-e438.
COVID-19 restrictions and patient safety concerns have greatly expanded the use of telehealth and virtual visits. Through patient satisfaction surveys and patient complaints, this US hospital evaluated the quality and safety of virtual visits in March and April of 2020. Five patient complaints were submitted during this timeframe and overall patient satisfaction remained high. Safety and quality risks were identified (e.g., diagnostic error) and best practices were established.
Lamoureux C, Hanna TN, Sprecher D, et al. Emerg Radiol. 2021;28:1135-1141.
Teleradiology - general radiologists who support several hospitals and read films remotely – can increase off-hours coverage but this approach can result in increased errors. This retrospective review examined errors and discrepancies between teleradiology findings and image interpretation from local facility radiologists. Most errors involved CT scans; the most common errors included missed fractures or dislocations and bleeding.

Perry AF, Federico F, Huebner J. Boston, MA: Institute for Healthcare Improvement; 2021. 

The emergence of telemedicine during the COVID-19 pandemic has situated it to become an accepted model for health service provision despite safety concerns. This white paper discusses a 6-item framework to enhance the safety, equity, and person-centeredness of telemedicine and recommendations for embedding safer methods into telemedicine practice.
Patient Safety Primer February 24, 2022
Residents living in nursing homes or residential care facilities use common dining and activity spaces and may share rooms, which increases the risk for transmission of COVID-19 infection. This document describes key patient safety challenges facing older adults living in these settings, who are particularly vulnerable to the effects of the virus, and identifies federal guidelines and resources related to COVID-19 prevention and mitigation in long-term care. As of April 13, 2020, the Associated
Berntsson K, Eliasson M, Beckman L. BMC Nurs. 2022;21:24.
Safe and accurate telephone triage is of critical importance, particularly during the COVID-19 pandemic. This Swedish study evaluated district nurses’ experiences and perceptions of patient safety at a national nurse advice triage call center. Interviews with nurses resulted in an overall theme of “being able to make the right decision” based on the categories of “communication” and “assessment.”
Khoong EC, Sharma AE, Gupta K, et al. J Gen Intern Med. 2022;37:1270-1274.
In response to concerns about COVID-19 transmission, many ambulatory care visits have transitioned to telehealth visits. This commentary describes the impact of telehealth on diagnostic errors and medication safety in ambulatory settings. Recommendations to further understand the impact of telemedicine on patient safety include: systematically measuring patient safety outcomes and increasing reporting of safety incidents; identifying the patients and clinical scenarios with the greatest risk of unsafe telehealth care; identifying and supporting best practices to ensure equal access to safe telehealth.