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Innovations
The PSNet Innovations page highlights pioneering advances that can improve patient safety. PSNet innovations are defined as “new or updated interventions, approaches, systems, tools, policies, organizational structures or business models implemented to improve or enhance quality of care and reduce harm.” The PSNet Innovations page includes innovations developed, tested, and sustained within the past five years, updates to existing innovations that were featured in AHRQ’s Health Care Innovations Exchange, as well as “emerging innovations,” which are new, novel approaches to patient safety improvement recently published in the peer-reviewed literature.
Latest Innovations
Addressing diagnostic errors to improve outcomes and patient safety has long been a problem in the US healthcare system.1 Many methods of reducing diagnostic error focus on individual factors and... Read More
Concern over patient safety issues associated with inadequate tracking of test results has grown over the last decade, as it can lead to delays in the recognition of abnormal test results and the absence of a tracking system to... Read More
To address a well-documented hospital adverse outcome (in-hospital patient clinical deterioration), Kaiser Permanente Northern California (KPNC) developed and implemented the... Read More
Seeking a sustainable process to enhance their hospitals’ response to sepsis, a multidisciplinary team at WellSpan Health oversaw the development and implementation of a system that uses customized electronic health... Read More
Emerging Innovations
Although wrong-site surgeries are rare, they can be devastating to patients. One otolaryngology (ENT) clinic developed a surgical marking procedure deemed practicable and useful by both providers and patients.
Cognitively impaired patients may be at increased risk of adverse events, such as falls, and assessment of cognitive status and implementation of appropriate supports is needed to improve their safety.
Minoritized patients continue to experience disproportionately high rates of maternal morbidity and mortality. This hospital developed a health-equity checklist to identify if bias and/or social determinants of health played a role in preventable... Read More
Medication reconciliation is a common strategy to improve patient safety but is complex and time consuming. Three academic medical centers developed and implemented a risk stratification tool so limited pharmacist resources could be allocated to... Read More
Situational awareness during complex care events, such as clinical deterioration, medication administration, or the admission process, is an important component of teamwork and high reliability. This Canadian hospital used technology and human... Read More
All Innovations (54)
In the early days of the COVID-19 pandemic, New York Presbyterian Weill Cornell Medical Center and Lower Manhattan Hospital faced multiple challenges.
The Revised Safer Dx Instrument provides a standardized list of questions to help users retrospectively identify and assess the likelihood of a missed diagnosis in a healthcare episode. Results of the assessment are intended for use in system-level safety improvement efforts, clinician feedback, and patient safety research.
The Veterans Health Administration (VHA) Stratification Tool for Opioid Risk Mitigation (STORM) decision support system and targeted prevention program were designed to help mitigate risk factors for overdose and suicide among veterans who are prescribed opioids and/or with opioid use disorder (OUD) and are served by the VHA.1 Veterans, particularly those prescribed opioids, experience overdose and suicide events at roughly twice
The team at Geisinger sought to develop an outpatient addiction medicine specialty program that incorporated medication-assisted treatment (MAT), peer support, and connection to community counseling services and uses data-driven insights to monitor and improve patient outcomes. As a result of this program, they have been able to reduce all-cause mortality among these patients, increase patient engagement in substance use disorder treatment, and have seen a reduction in the prescription quantities of controlled substances.
