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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
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
Studies show that home visits to patients recently discharged from the hospital can help prevent unnecessary readmission.1 Providing continuing care instructions to patients in their homes—where they may be less overwhelmed than in the hospital—may... Read More
Emerging Innovations
A lack of situational awareness can lead to delayed recognition of patient deterioration. This children’s hospital developed and implemented a situational awareness framework designed to decrease emergency transfers to the intensive care unit (ICU).... Read More
Obtaining a best possible medication history is the cornerstone of medication reconciliation but can be resource-intensive. This comparison study assessed the impact of virtual pharmacy technicians (vCPhT) obtaining best possible... Read More
Checklists are used in many clinical settings to improve patient safety. This pediatric intensive care unit updated a static checklist, eSIMPLE, to a dynamic, decision-support enhanced checklist, eSIMPLER. ... Read More
Mobile health apps are becoming increasingly popular for patients and clinicians. This innovative study implemented a pharmacist-led mobile health based intervention to improve medication safety of patients following kidney transplant. ... Read More
The relationship between burnout among healthcare workers and poor patient safety outcomes has been well-documented. The COVID-19 pandemic exacerbated burnout risk due to increased emotional exhaustion, stress, and fatigue. In response to effects of... Read More
All Innovations (35)
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.
