Clinical Areas

Browse using Clinical Area if you would like to explore PSNet by the healthcare profession, such as the nursing or medical specialty, featured in the resources.

Latest by Clinical Areas

WebAIRS Anesthesia Incident Reporting System.

Australian and New Zealand Tripartite Anaesthetic Data Committee.

Reporting errors in anesthesiology practice can motivate and inform safety improvement work. This website serves as a secure mechanism for submitting incident reports to a centralized... Read More

NPSD Data Spotlight: Patterns of Fall Interventions.

Rockville, MD: Agency for Healthcare Research and Quality; September 2023. AHRQ Publication no. 23-0055.

Intravenous (IV) push medications – bridging the gap between education and clinical practice.

ISMP Medication Safety Alert! Acute Care. November 2, 2023;28(22):1-4.

Intravenous (IV) push medication administration is a primary therapeutic approach where process gaps can result in harm. This article examines existent... Read More

Advancing Diagnostic Excellence for Maternal Health Care: Proceedings of a Workshop–in Brief.

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... Read More

All Clinical Areas (2657)

Clear all filter(s)

Displaying 1 - 20 of 2657 Results

Using stakeholder intervention refinement teams to develop approaches for real-time integration of patient-reported safety information during older adults’ hospital-to-home-health care transitions.

Save to Library

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.

NPSD Data Spotlight: Patterns of Fall Interventions.

Save to Library

Rockville, MD: Agency for Healthcare Research and Quality; September 2023. AHRQ Publication no. 23-0055.

Falls are a frequently reported sentinel event. This Data Spotlight from AHRQ’s Network of Patient Safety Databases (NPSD) highlights the most common interventions in place among patients who experienced a fall such as nonslip wear, bed height and visible risk identification. Data for the analysis includes reports on patient safety concerns submitted from 2009 through 2021.

Intravenous (IV) push medications – bridging the gap between education and clinical practice.

Save to Library

ISMP Medication Safety Alert! Acute Care. November 2, 2023;28(22):1-4.

Intravenous (IV) push medication administration is a primary therapeutic approach where process gaps can result in harm. This article examines existent presence of recognized safe practice education in close to 200 surveyed nursing programs to assess the teaching of standardized practice behaviors at the student level and recommend strategies to embed IV safety into instruction efforts.

Advancing Diagnostic Excellence for Maternal Health Care: Proceedings of a Workshop–in Brief.

Save to Library

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.

Technology, Education and Safety

Save to Library

Arnal-Velasco, D, ed. Curr Opin Anaesthesiol. 2023;36(6):649-705.

Adoption of new ideas is necessary to create safety in the perioperative environment. This collection of reviews illustrates relationships and tensions between technology, human factors and safety management that create the sociotechnical system within which technology is used to deliver anesthesia. Topics covered include artificial intelligence, decision making and perioperative deterioration.

Room for resilience: a qualitative study about accountability mechanisms in the relation between work-as-done (WAD) and work-as-imagined (WAI) in hospitals.

Save to Library

Weenink J-W, Tresfon J, van de Voort I, et al. BMC Health Serv Res. 2023;23:1048.

Promoting resilience across and within healthcare organizations is a key component of Safety-II. This qualitative study involving six teams across three hospitals in the Netherlands found that healthcare professionals, managers, and quality advisors hold differing perspectives regarding the right approach to clinical practices and the importance of certain clinical actions. The authors underscore the importance of team reflections to foster resilience and accountability across all levels within healthcare organizations.

Alarm burden and the nursing care environment: a 213-hospital cross-sectional study.

Save to Library

Ruppel H, Dougherty M, Bonafide CP, et al. BMJ Open Qual. 2023;12:e002342.

Alarm fatigue can lead to desensitization to safety alerts and threaten patient safety. In this survey of 3,986 registered nurses, the majority (83%) reported alarm fatigue and over half (55%) experienced a situation where an alarm went unchecked despite a patient requiring urgent attention. The researchers found that alarm burden was more common among respondents who rated their hospital’s safety as poor or reported poor work environments.

The benefits and opportunities: engaging patients in identifying and reporting patient safety incidents.

Save to Library

Pozzobon LD, Rotter T, Sears K. Healthc Manage Forum. 2023;Epub Oct 13.

Patient and caregiver engagement in patient safety can improve individual outcomes and help identify safety threats. This article highlights the advantages of including patients in patient safety event reporting, including broadening the understanding of harm to include psychological and financial harms, identifying contributing factors to harm, and notes several organizational activities where patients and caregiver involvement can be integrated.

Authentic leadership at the Cleveland Clinic: psychological safety in the midst of crisis.

Save to Library

Porter TH, Peck JA, Bolwell B, et al. BMJ Lead. 2023;7:196-202.

Authentic leadership principles emphasize the influence of positive psychological capacities to foster self-awareness and self-regulated positive behaviors. This qualitative study used podcast transcripts to explore the experiences of senior leadership during the COVID-19 pandemic and the role of authentic leadership principles. The researchers identified several behaviors demonstrating authentic leadership and discuss its influence of psychological safety, particularly during a crisis.

Effect of complementary interventions to redesign care on teamwork and quality for hospitalized medical patients: a pragmatic controlled trial.

Save to Library

O’Leary KJ, Johnson JK, Williams MV, et al. Ann Intern Med. 2023;Epub Oct 31.

Teamwork is an essential component of ensuring high quality, safe healthcare. This article describes findings from the Redesigning SystEms to Improve Teamwork and Quality for Hospitalized Patients (RESET) study, which evaluated the impact of complementary interventions to redesign unit-based care (unit-based physician teams, nurse-physician co-leadership, interprofessional rounds, performance reports, patient engagement) on interprofessional teamwork and patient outcomes. Findings demonstrate improved teamwork climate scores among nurses (but not physicians), but researchers did not identify a significant impact on patient outcomes.

A study of error reporting by nurses: the significant impact of nursing team dynamics.

Save to Library

Munn LT, Lynn MR, Knafl GJ, et al. J Res Nurs. 2023;28:354-364.

Nursing team dynamics can influence safety culture and willingness so speak up about errors and safety concerns. This survey of over 650 nurses and nurse managers underscored the importance of leader inclusiveness, safety climate, and psychological safety in cultivating speaking up behaviors among nursing team members.

Preventing nosocomial bloodstream infections (NBSIs) by implementing hospitalwide, department-level, self-investigations: a NBSIs frontline ownership intervention.

Save to Library

Mudrik-Zohar H, Chowers M, Temkin E, et al. Infect Control Hosp Epidemiol. 2023;44:1562-1568.

Nosocomial infections remain a persistent patient safety issue and can lead to serious patient harm. This article describes one Israeli hospital’s experience using department-level investigations to reduce the incidence of nosocomial bloodstream infections. Study findings demonstrated that department-level investigations coupled with increased staff awareness led to significant reductions in nosocomial bloodstream infections.

Anesthesia workspaces for safe medication practices: design guidelines.

Save to Library

MohammadiGorji S, Joseph A, Mihandoust S, et al. HERD. 2023;Epub Aug 8.

Well-designed workspaces minimize disruptions and distractions. This review and study describes several important ways to improve the anesthesia workspace in the operating room. Recommendations include demarcating an anesthesia zone with adequate space for equipment and storage and that restricts unnecessary staff travel into and through the zone. Each recommendation includes an illustrative diagram, explains its importance, and offers methods to achieve it.

Facilitators and barriers to the implementation of surgical safety checklist (SSC): an integrative review.

Save to Library

Lim PJH, Chen L, Siow S, et al. Int J Qual Health Care. 2023;35:mzad086.

Surgical safety checklists (SCC) are utilized around the world, but checklist completion at the operating room level remains inconsistent. This review summarizes facilitators and barriers to completion. Resistance or endorsement at the individual surgeon level remains a significant factor in SSC completion. Early inclusion of frontline staff in evaluation and implementation supported increased use.

An exploratory analysis of the association between hospital quality measures and financial performance.

Save to Library

Beauvais B, Dolezel D, Ramamonjiarivelo Z. Healthcare (Basel). 2023;11:2758.

Patient safety improvement efforts involve financial expenditures, which means that hospital leaders must evaluate their return on investment. This study examines the association of several quality-of-care measures and hospital profitability as measured by patient revenue per adjusted discharge. Better patient satisfaction, lower readmission rates, and three of the four Hospital Value-Based Purchasing Program (HVBP) domains were associated with improved financial outcomes.

Network of Patient Safety Databases Chartbook.

Save to Library

Rockville, MD: Agency for Healthcare Research and Quality; September 2023. AHRQ Publication no. 23-0082.

The sharing of data is a core element of a learning health system. AHRQ has released the Network of Patient Safety Databases (NPSD) Chartbook 2023, which offers an overview of nonidentifiable, aggregated patient safety event and near-miss information, voluntarily reported by AHRQ-listed Patient Safety Organizations across the country between June 2014 and December 2022. The chartbook outlines the extent of harm reported, distribution of patient safety events, near misses, and unsafe conditions.

Inappropriate prescribing to older patients by nurse practitioners and primary care physicians.

Save to Library

Huynh J, Alim SA, Chan DC, et al. Ann Intern Med. 2023;Epub Oct 14.

Access to primary care is becoming more challenging, in part due to physicians leaving the field. Twenty-nine states have expanded nurse practitioner (NP) autonomy to increase access. This study compares potentially inappropriate prescribing practices between NPs and primary care physicians (PCP). In the study population, adults aged 65 and older, NPs and PCPs had nearly identical rates of potentially inappropriate prescribing. The authors encourage focusing on improving prescribing practices among all prescribers instead of working to limit prescribing to physicians.

Use of the Second Victim Experience and Support Tool (SVEST) to assess the impact of a departmental peer support program on anesthesia professionals' second victim experiences (SVEs) and perceptions of support two years after implementation.

Save to Library

Pelikan M, Finney RE, Jacob A. AANA J. 2023;91(5):371-379.

Providers involved in patient safety incidents can experience adverse psychological and physiological outcomes, also referred to as second victim experiences (SVE). This study used the Second Victim Experience and Support Tool (SVEST) to evaluate the impact of a peer support program on anesthesia providers’ SVE. Two years after program implementation, reported psychological distress decreased and over 80% of participants expressed favorable views of the program and its impact on safety culture.

Identifying barriers and enablers for a robust independent second check of medication in adult intensive care.

Save to Library

Milic V, Cameron L, Jones C. Br J Nurs. 2023;32:840-848.

Double checking of medication administration one strategy meant to reduce medication errors. In this study, 29 critical care nurses took part in a focus group exploring the barriers to double-checking during medication administration. Participants discussed several challenges, such as patient location (particularly for patients in isolation due to infection control measure), health IT limitations, and unclear roles and responsibilities.

Preferred language and diagnostic errors in the pediatric emergency department.

Save to Library

Lowe JT, Leonard J, Dominguez F, et al. Diagnosis (Berl). 2023;Epub Oct 6.

Non-English primary language (NEPL) patients may encounter barriers navigating the healthcare system and communicating with providers. In this retrospective study, researchers used the Safer Dx tool to explore differences in diagnostic errors among NEPL versus English-proficient (EP) patients. Among 172 patients who experienced a diagnostic error, the proportion was similar among EP and NEPL groups and NEPL did not predict higher odds of diagnostic error.

Clinical Areas

Latest by Clinical Areas

All Clinical Areas (2657)

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Clinical Areas

Latest by Clinical Areas

All Clinical Areas (2657)

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site