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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 318 Results
Trout KE, Chen L-W, Wilson FA, et al. Int J Environ Res Public Health. 2022;19:12525.
Electronic health record (EHR) implementation can contribute to safe care. This study examined the impact of EHR meaningful use performance thresholds on patient safety events. Researchers found that neither full EHR implementation nor achieving meaningful use thresholds were associated with a composite patient safety score, suggesting that hospitals may need to explore ways to better leverage EHRs and as well other strategies to improve patient safety, such as process improvement and staff training.
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.
Neely J, Sampath R, Kirkbride G, et al. J Correct Health Care. 2022;28:141-147.
Incarcerated individuals face unique patient safety threats. Based on a collaboration between the Illinois Department of Corrections and the University of Illinois College of Nursing, this article describes a plan for improving the quality and safety of healthcare for the state’s incarcerated population.  
Wiering B, Lyratzopoulos G, Hamilton W, et al. BMJ Qual Saf. 2022;31:579-589.
Delays in cancer diagnosis and treatment can lead to significant morbidity and mortality. This retrospective study linking data reflecting primary and secondary care as well as cancer registry data found that only 40% of patients presenting with common possible cancer features received an urgent referral to specialist care within 14 days. Findings revealed that a significant number of these patients developed cancer within one year. 

Am J Health Syst Pharm. 2022;79(7): 564-599.

Pharmacists have a central role in ensuring medication safety during healthcare delivery. This report outlines standards for the delivery of safe, high-quality pharmacy services including how pharmacy departments should be placed within the health system and how health system processes can support safe medication use and pharmacy practice.

Fed Register. February 10, 2022;87: 7838-7840.

The 2016 Centers for Disease Control opioid guidelines have raised concerns as to their potential to contribute to patient harm. This announcement calls for comments from the field to inform and update current policy in response to safety issues that emerged as unintended consequences of the 2016 recommendation. Comments are due to be submitted by April 11, 2022.
Townsend T, Cerdá M, Bohnert AS, et al. Health Aff (Millwood). 2021;40:1766-1775.
Misuse of prescription opioids represents a serious patient safety issue. Using commercial claims from 2014 - 2018, researchers examined the association between the 2016 CDC guidelines to reduce unsafe opioid prescribing and opioid dispensing for patients with four common chronic pain diagnoses. Findings indicate that the release of the 2016 guidelines was associated with reductions in the percentage of patients receiving opioids, average dose prescribed, percentage receiving high-dose prescriptions, number of days supplied, and the percentage of patients receiving concurrent opioid/benzodiazepine prescriptions. The authors observe that questions remain about how clinicians are tailoring opioid reductions using a patient-centered approach.
Curated Libraries
September 13, 2021
Ensuring maternal safety is a patient safety priority. This library reflects a curated selection of PSNet content focused on improving maternal safety. Included resources explore strategies with the potential to improve maternal care delivery and outcomes, such as high reliability, care standardization,teamwork, unit-based safety initiatives, and...
Agnoli A, Xing G, Tancredi DJ, et al. JAMA. 2021;326:411-419.
Sudden discontinuation of opioids has been linked to increased patient harm. This observational study evaluated the link between tapering and overdose, and mental health crisis among patients who were receiving long-term opioid therapy. Patients who underwent dose tapering had an increased risk of overdose and mental health crisis compared to those who did not undergo dose tapering. 
Cheraghi-Sohi S, Holland F, Singh H, et al. BMJ Qual Saf. 2021;30:977-985.
Diagnostic error continues to be a source of preventable patient harm. The authors undertook a retrospective review of primary care consultations to identify incidence, origin and avoidable harm of missed diagnostic opportunities (MDO). Nearly three-quarters of MDO involved multiple process breakdowns (e.g., history taking, misinterpretation of diagnostic tests, or lack of follow up). Just over one third resulted in moderate to severe avoidable patient harm. Because the majority of MDO involve several contributing factors, interventions, including policy changes, should be multipronged.
Barranco R, Vallega Bernucci Du Tremoul L, Ventura F. Int J Environ Res Public Health. 2021;18:489.
Health systems have implemented various strategies to reduce the risk of nosocomial transmission of the COVID-19 virus. Based on ten studies, the authors estimate that the nosocomial transmission rate is 12-15%. The authors discuss the role of infection prevention and control procedures, and the potential implications of hospital-acquired COVID-19 on medical malpractice.  
Wessels R, McCorkle LM. J Healthc Risk Manag. 2021;40:30-37.
The COVID-19 pandemic has disrupted healthcare delivery. This study reviewed data from a large medical professional liability company to explore guidance sought by physicians and dentists during the initial months of the pandemic. Providers’ questions and concerns primarily involved operations (e.g., access to personal protective equipment, liability coverage), patient care (e.g., guidance for screening patients), scope of practice, and use of telemedicine.    
Brown KW, Carlisle K, Raman SR, et al. Health Aff (Milwood). 2020;39:1737-1742.
Over the last decade, children have experienced a dramatic rise in hospitalizations and intensive care unit stays related to opioid use. Based on Medicaid claims in North Carolina, prescribers of opioids for children were most commonly physicians and dentists. More than 3% of children ages 1 to 17 years had at least one opioid prescription filled annually; 76.6 children per 100,000 experienced an opioid-related adverse event or other harm. Adolescents ages 15 to 17 years disproportionately experienced these harms compared to younger age groups. Black and urban children were less likely to fill opioid prescriptions or experience adverse events, but they were more likely to experience other opioid-related harm, such as abuse or dependence.   

Garman AN, McAlearney AS, Harrison MI, et al. Health Care Manag Rev. 2011-2020.

In this continuing series, high-performance work practices are explored and defined through literature review, case analysis, and research. The authors summarize findings and discuss how best practices can influence quality, safety, and efficiency outcomes. Topics covered include speaking up, central line infection prevention, and business case development.
Fink BC, Uyttebrouck O, Larson RS. J Law Med Ethics. 2020;48:249-258.
The overprescribing of opiates is a known contributor to the opioid epidemic. This essay describes governmental action taken to adjust prescribing patterns, their effect, and strategies to increase the impact of these actions on opioid misuse and patient harm.
Noursi S, Saluja B, Richey L. J Racial Ethn Health Disparities. 2021;8:661-669.
This study used ecological systems theory to review the literature on the root causes of racial disparities in maternal morbidity and mortality at the individual, interpersonal, community, and societal levels. Factors influencing disparities include access to preconception and prenatal care, implicit bias among health care providers, the need for quality improvement among black-serving hospitals, and policies such as parental leave. The authors also identify interventions likely to reduce disparities, such as improving health professional education, alternate prenatal care providers, and reforming Medicaid policies.