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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)
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).
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 medication histories from patients admitted to the hospital from the emergency department.
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.
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.
The relationship between burnout among healthcare workers and poor patient safety outcomes has been well-documented
Understanding the ways in which human factors, such as non-technical skills, influence individual and team performance can ultimately improve patient safety, particularly in high-intensity settings such as operating rooms.
Medication administration errors are a common source of patient harm.
The handshake antimicrobial stewardship program (HS-ASP) was developed and implemented at Children’s Hospital Colorado (CHCO). In 2014, the CHOC HS-ASP team began labeling specific interventions as “Great Catches” which were considered to have altered, or had the potential to alter, the patient’s trajectory of care. CHOC researchers used these "Great Catches" to identify potential diagnostic errors.
