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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)
During a time of unprecedented patient volume and clinical uncertainty, a diverse team of health system administrators and clinicians within the University of Pennsylvania Health System quickly investigated, updated, and disseminated airway management protocols after several airway safety incidents occurred among COVID-19 patients who were mechanically ventilated. Based on this experience, the team created the I-READI framework as a guide for healthcare systems to prepare for and quickly respond to quality and safety crises.1
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 identify and reduce the number of alerts clinicians encounter every day.
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 implementation of an electronic health record-based referral system for patients with incidental radiologic finding in the emergency room.
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.
Rapid response teams are intended to improve timely identification and management of clinically deteriorating patients, such as in-hospital cardiac arrest or stroke.
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.
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-department training experiences.1,2 As a tool to leverage resident potential and improve reporting of safety events, some evidence supports the use of resident-led training and hands-on activities.3,4 Yet, while there are many studies on patient
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 Medical Center (VAMC) started a transitional care clinic (TCC) led by clinical pharmacy specialists (CPSs) who provide follow-up care to patients after they are discharged from the hospital or emergency department (ED). CPSs are independent mi
In the early days of the COVID-19 pandemic, New York Presbyterian Weill Cornell Medical Center and Lower Manhattan Hospital faced multiple challenges.
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 also be a key mechanism for preventing readmission.2 Home visit clinicians and technicians can note any health concerns in the home environment and help patients understand their care plan in the context of that environment.2
Venous thromboembolism (VTE) is a serious but preventable medical condition in which blood clots form in the veins.
An increasing volume of patients presenting for acute care can create a need for more ICU beds and intensivists and lead to longer wait times and boarding of critically ill patients in the emergency department (ED).1 Data suggest that boarding of critically ill patients for more than 6 hours in the emergency department leads to poorer outcomes and increased mortality.2,3 To address this issue, University of Michigan Health, part of Michigan Medicine, developed an ED-based ICU, the first of its kind, in its 1,000-bed adult hospital.
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.
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.
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.
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).
With the PICC Use Initiative, the Michigan HMS, which currently includes 62 non-governmental hospitals in Michigan, aims to improve the safety of hospitalized patients by eliminating unnecessary PICC use and preventing PICC-associated complications. Since infectious diseases (ID) physician approval for PICC use is one promising strategy to reduce inappropriate use, the consortium helped promote and facilitate data collection for this patient safety strategy.
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
