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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)
ECHO-Care Transitions (ECHO-CT) intends to ensure continuity of care and alleviate the risk of patient safety issues, notably medication errors, occurring because of hospital transition. With funding from the Agency for Healthcare Research and Quality, Beth Israel Deaconess Medical Center (BIDMC) adapted Project Extension for Community Healthcare Outcomes (ECHO) to connect receiving multidisciplinary skilled nursing facility (SNF) teams with a multidisciplinary team at the discharging hospital.
The Patient Safe-D(ischarge) program used standardized tools to educate patients about their discharge needs, test understanding of those needs, and improve medication reconciliation at admission and discharge. A quasi-randomized controlled trial of the program found that it significantly increased patients' understanding and knowledge of their diagnoses, treatment, and required follow-up care.
Multidisciplinary teams at the University of Kansas Hospital sought to improve patient outcomes from obstetric emergencies by rehearsing team responses in simulations to emergent situations that can occur during a delivery. Using the PRactical Obstetric MultiProfessional Training (or PROMPT) curriculum, teams rehearsed flexible emergency care scenarios in order to achieve an optimal response, and then used this experience to improve their response to a real emergency.
Formerly known as the Antenatal and Neonatal Guidelines, Education and Learning System (ANGELS), the University of Arkansas for Medical Sciences (UAMS) High-Risk Pregnancy Program links clinicians and patients across the state with UAMS, where the vast majority of the state's high-risk pregnancy services, maternal-fetal medicine specialists, and prenatal genetic counselors are located.
The Support and Services at Home (SASH®) program provides onsite assistance to help senior citizens (and other Medicare beneficiaries) remain in their homes as they age. Using evidence-based practices, a multidisciplinary, onsite team conducts an initial health assessment, creates an individualized care plan based on each participant’s self-identified goals, provides onsite nursing and care coordination with local partners, and schedules community activities to support health and wellness.
