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 19282 Results

Fact Sheet/FAQs

ISMP List of Error-Prone Abbreviations, Symbols, and Dose Designations.

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Horsham, PA; Institute for Safe Medication Practices; April 17, 2024.

A handy list for medical personnel to ensure and implement safe prescribing practices by avoiding use of these dangerous shortcuts.

Study

"Black Women Should Not Die Giving Life": The lived experiences of Black women diagnosed with severe maternal morbidity in the United States.

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Post W, Thomas AD, Sutton KM. Birth. 2024;Epub Apr 2.

Structural racism and discrimination can impede safe maternal care. This qualitative study among Black women highlighted how their severe maternal morbidity (SMM) experiences relate to manifestations of racism through communication failures and stereotyping, differential treatment, and medical errors/near misses.

Study

Impact of repeated reimbursement penalties on hospital total quality scores.

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Brewer A, Hughes MC, Patel KN. J Patient Saf. 2024;20:198-201.

The Hospital-Acquired Condition (HAC) Reduction Program (HACRP) assesses penalties on hospitals with high rates of HAC. This study explores the impact of repeated HACRP penalties on hospital improvement and variation by hospital characteristics. When considering all hospitals, repeated HACRP penalties resulted in improved HAC scores. Hospitals with disproportionate shares of Medicare and Medicaid patients showed less improvement; the researchers note that the differential improvement may be due to resource limitations at hospitals serving vulnerable populations (i.e., Medicare and Medicaid patients).

Review

Unmasking bias in artificial intelligence: a systematic review of bias detection and mitigation strategies in electronic health record-based models.

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Chen F, Wang L, Hong J, et al. J Am Med Inform Assoc. 2024;Epub Mar 23.

When biased data are used for research, the results may reflect the same biases if appropriate precautions are not taken. In this systematic review, researchers describe possible types of bias (e.g., implicit, selection) that can result from research with artificial intelligence (AI) using electronic health record (EHR) data. Along with recommendations to reduce introducing bias into the data model, the authors stress the importance of standardized reporting of model development and real-world testing.

Study

An electronic trigger to detect telemedicine-related diagnostic errors.

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Murphy DR, Kadiyala H, Wei L, et al. J Telemed Telecare. 2024;Epub Apr 1.

The expansion of telehealth has improved access to care, but concerns have been raised about potential for diagnostic errors. In this study, researchers used the Safer Dx Trigger tool framework to develop an electronic trigger to identify delayed diagnoses during primary care telehealth visits at a Veterans Health Affairs (VHA) facility. Applying the trigger tool to a random sample of 100 telehealth visits with a subsequent unplanned visit (emergency department, hospital or primary care) yielded a positive predictive value of 11%.

Study

Understanding the informal aspects of medication processes to maintain patient safety in hospitals: a sociotechnical ethnographic study in paediatric units.

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Sutherland AB, Phipps DL, Grant S, et al. Ergonomics. 2024;Epub Apr 1.

Medication errors are often the result of both individual failures and system flaws. This qualitative study found that medication safety practices in pediatric inpatient units are often hindered by issues in the physical environment (e.g., workspace layouts, interruptions) and by poorly integrated workflows.

Review

Inattentional blindness in medicine.

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Hults CM, Ding Y, Xie GG, et al. Cogn Res Princ Implic. 2024;9:18.

Inattentional blindness occurs when a person is focused so intently on one task that they miss other important information. This review identifies studies of inattentional blindness in healthcare, from radiology to surgery to nursing. The authors make recommendations on how to improve designing and reporting studies of inattentional blindness.

Newspaper/Magazine Article

Guardians of grafts: reducing medication errors in transplant recipients.

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ISMP Medication Safety Alert! Acute care. April 4, 2024;29(7):1-4.

Safe medication therapy for transplant patients is complex and has the potential for serious harm when errors occur. This article reports on an analysis of 520 transplant medication-related errors to summarize the types of mistakes that occurred, and to provide suggestions for improvement that emphasize medication reconciliation, order set development, and clinical decision support use.

Study

Associations between organizational communication and patients' experience of prolonged emotional impact following medical errors.

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Sokol-Hessner L, Dechen T, Folcarelli P, et al. Jt Comm J Qual Patient Saf. 2024;Epub Mar 7.

Medical errors can cause physical, financial, or emotional harm to patients. This survey identified prolonged emotional impacts (greater than one year) among the majority of US adults who experienced a medical error. Survey respondents who were female or with a lower socioeconomic status were more likely to report prolonged emotional impacts; organizational factors such as lack of organizational disclosure guidelines and no patient or family reporting process also increased risk of prolonged emotional impacts.

Study

Estimating the impact on patient safety of enabling the digital transfer of patients' prescription information in the English NHS.

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Camacho EM, Gavan S, Keers RN, et al. BMJ Qual Saf. 2024;Epub Mar 26.

Transitions of care introduce risk of medication errors, even with interoperable electronic medication systems; systems that do not communicate with each other introduce even more risk. This study estimates the prevalence and burden of medication errors at transitions of care (hospital admission, hospital discharge, transfers between hospitals, and transfers within hospitals) when electronic medication records are not interoperable. Implementing interoperable prescribing systems could significantly reduce the number of errors and prevent medication error-related patient deaths.

United States Meeting/Conference

AHRQ EPC Program Grand Rounds - Making Healthcare Safer.

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Agency for Healthcare Research and Quality Evidence-based Practice Center and the Scientific Resource Center. April 29, 2024, 12:00-2:00 PM (eastern)

A commitment to evidence-based improvement is core to patient safety achievement. This webinar will highlight three reports from the Making Healthcare Safer IV series covering opioid stewardship, rapid response systems, and the involvement of family caregivers as participants in structured communication during care transitions.

Commentary

Why talking is not cheap: adverse events and informal communication.

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Montgomery A, Lainidi O, Georganta K. Healthcare (Basel). 2024;12:635.

A strong safety culture relies on staff formally reporting or speaking up about adverse events (AE), yet valid reasons exist to explain why staff may choose not to. This article argues that although staff may not be using formal channels to report AE, they are engaging in informal communication. Using high-profile adverse events, the authors describe the important role gossip plays in sense-making and how leadership would do well to listen to this informal communication.

Review

An integrative systematic review of promoting patient safety within prehospital emergency medical services by paramedics: a role theory perspective.

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Strandås M, Vizcaya-Moreno M, Ingstad K, et al. J Multidiscip Healthc. 2024;17:1385-1400.

Paramedics often provide critical medical care during complex, high-stress scenarios. This systematic review of 16 studies found that paramedics encounter a myriad of challenges in maintaining safe patient care (e.g., uncertainties about role expectations, insufficient resources). Studies highlighted the effectiveness of interventions to increase technical and non-technical skills and improve communication and collaboration to promote patient safety.

Commentary

Bad behavior in healthcare: an insidious threat to patients, staff, and organizations.

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Crowe L, Riley CM. Curr Opin Cardiol. 2024;Epub Mar 21.

Unprofessional behavior negatively impacts the work environment, team functioning, and patient safety. Women, minoritized, and junior staff are more likely to be the targets of unprofessional behavior and are less likely to report it due to fear of retaliation or thinking nothing will be done to curb the perpetrator's behavior. Clear and consistent organizational commitment to address unprofessional behavior can mediate many of the negative patient safety impacts.

Book/Report

Discharge from Mental Health Care: Making it Safe and Patient-centred.

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Manchester, UK: Parliamentary and Health Service Ombudsman; March 2024.

The provision of safe mental health care is receiving increased attention as an area of concern. This report examined six incidents of poor discharge care for patients with mental health conditions. The authors highlight system issues exacerbating the failures discussed and provide recommendations for improvement.

Study

Clinical reasoning of a generative artificial intelligence model compared with physicians.

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Cabral S, Restrepo D, Kanjee Z, et al. JAMA Intern Med. 2024;Epub Apr 1.

Research into how large language models (LLM) such as ChatGPT can be used in healthcare is growing rapidly. This study compared ChatGPT and physicians' clinical reasoning in a simulated case study. Using the validated Revised-IDEA (R-IDEA) framework, the LLM performed better than physicians did in processing medical data and clinical reasoning; there were no differences observed using other frameworks.

Book/Report

Retained Swabs Following Invasive Procedures: Themes Identified from a Review of NHS Serious Incident Reports.

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Dorset, UK: Health Services Safety Investigations Body; April 2024.

Retained surgical items are never events that continue to occur despite efforts to reduce their occurrence. This report examines reasons for 31 incidents of retained surgical swabs reported in the United Kingdom’s National Health Service (NHS). Recommendations from the analysis focus on organizational work to limit the opportunities for swab retention that target system improvement rather those that lower impact changes directed toward staff behavior and training.

WebM&M Cases

Misplaced Nasogastric Tube Resulting in Aspiration

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WebM&M Case April 10, 2024

An 82-year-old woman presented to the emergency department for evaluation of “altered mental status” after falling down 5 step-stairs at home. She had a Glasgow Coma Score of 11 (indicating decreased alertness) on arrival. Computed tomography (CT) of the head revealed a right thalamic hemorrhage. She was admitted to the Vascular Neurology service. Overnight, the patient developed atrial fibrillation with rapid ventricular rate (RVR), which required medications for rate control.

Patient Safety Innovations

Risk Mitigation Using the Anesthesia Risk Alert Program: Applying a Proactive Approach With Data Review & Collaborating With a Second Practitioner

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Patient Safety Innovation April 10, 2024

North American Partners in Anesthesia (NAPA) is a nationwide anesthesia practice with more than 450 facilities in 21 states. NAPA employs anesthesiologists, certified registered nurse anesthetists, and certified anesthesiologist assistants.

WebM&M Cases

Hindsight is 20/20: Thrombolytics for Alcohol Intoxication

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WebM&M Case April 10, 2024

A 61-year-old patient presented to the emergency department (ED) complaining of weakness with findings of shuffling gait, slurred speech, delayed response to questions, and inability to concentrate or make eye contact. A stroke alert was activated and a neurosurgeon evaluated the patient via teleconsult. There was no intracranial hemorrhage identified on non-contrast computed tomography (CT) of the head and the neurosurgeon recommended administering Tenecteplase (TNK).

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