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Innovations
The PSNet Innovations Exchange highlights pioneering advances that can improve patient safety. PSNet innovations are defined as “new or altered products, tools, services, processes, systems, policies, organizational structures, or business models implemented to improve or enhance quality of care and reduce harm.” The PSNet Innovations Exchange includes recently developed and tested innovations, updates to existing innovations that have been featured in AHRQ’s Health Care Innovations Exchange, as well as “emerging innovations,” which are original approaches to patient safety recently published in the peer-reviewed literature.
Latest Innovations
Started in response to rising maternal morbidity and mortality rates in the State of California, the California Maternal Quality Care Collaborative (CMQCC) has conducted several statewide maternal safety and quality initiatives and has provided a... Read More
Medical residents, alongside interns, nurses and attending physicians, are uniquely positioned to identify safety concerns because they are on the front lines of patient care.1 Residents can bring a fresh perspective that is informed by their cross... Read More
Post-discharge adverse drug events (ADEs) are one of the most common preventable harms leading to hospital readmission in the United States.1,2 To improve medication-related safety and reduce hospital readmissions, the Memphis Veterans Affairs... Read More
In the early days of the COVID-19 pandemic, New York Presbyterian Weill Cornell Medical Center and Lower Manhattan Hospital faced multiple challenges. During the first COVID-19 surge, the hospital staff experienced a relatively high patient census,... Read More
Emerging Innovations
Community pharmacists encounter a wide range of challenges to medication safety. This study used a novel prospective method of predicting errors and developing remedial solutions.
Rapid response teams are intended to improve timely identification and management of clinically deteriorating patients, such as in-hospital cardiac arrest or stroke.
Patient falls are a never event and a frequent focus of patient safety and quality improvement projects. This pediatric ICU implemented a colored alert system based on fall risk assessments for all admitted patients.
Appropriate follow-up of incidental abnormal radiological findings is an ongoing patient safety challenge. Inadequate follow-up can contribute to missed or delayed diagnosis, potentially resulting in poorer patient outcomes. This study describes... Read More
While electronic health records, computerized provider order entry, and clinical decision support have increased patient safety, they can also create new challenges such as alert fatigue. One medical center developed and implemented a program to... Read More
All Innovations (41)
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 rate of the general population.1,2
Trauma staff at The Alfred Hospital use a computerized decision support system to guide the care of patients during the critical first 60 minutes of resuscitation. Known as the Trauma Reception and Resuscitation System (TR&R®), this program generates prompts based on more than 40 algorithms and real-time clinical data, including patient vital signs and information entered by a trauma nurse. Displayed on a large overhead monitor, these prompts are used by clinicians to direct the care of trauma patients and to facilitate documentation and communication.
Nudges are a change in the way choices are presented or information is framed that can have a large, but predictable, impact on medical decision-making, for both patients and providers without actually restricting individual choice. The Nudge Unit at Penn Medicine focuses on a range of different care improvement projects, including safety initiatives, with this framework in mind that are designed to improve workflow, support evidence-based decision-making, and create sustained changes in patient engagement and daily behaviors.1
