The PSNet Collection: All Content

The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.

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Displaying 1 - 20 of 399 Results

Prescription opioid dose reductions and potential adverse events: a multi-site observational cohort study in diverse US health systems.

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Metz VE, Ray GT, Palzes V, et al. J Gen Intern Med. 2023;Epub Nov 6.

In response to the increasing opioid crisis, many medical associations, policy makers, and insurers have argued for dose reductions. However, when doses are reduced too quickly, patients may experience short- and long-term adverse events. Consistent with other studies, dose reductions higher than 30% were associated with higher odds of emergency department visits, opioid overdose, and all-cause mortality in the month following dose reduction.

Surgical leadership in a culture of safety: an inter-professional study of metrics and tools for improving clinical practice.

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Gogalniceanu P, Kunduzi B, Ruckley C, et al. Am J Surg. 2023;Epub Sep 5.

Healthcare has borrowed many safety practices from aviation such as checklists, crew resource management, and safety culture. In this study, interviews with aviation experts identify non-technical skills that leaders require in a safety culture environment which the authors adapt for surgical leaders. The core attribute was "humble confidence," with three additional domains: management of risk, management of opportunity, and management of people. The authors developed the Safety Leadership Assessment Matrix (SLAM) to assess these non-technical skills in surgeon leaders.

Enhancing safety of a system-wide in situ simulation program using no-go considerations.

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Minors AM, Yusaf TC, Bentley SK, et al. Simul Healthc. 2023;18:226-231.

In situ simulations offer unique opportunities to improve teamwork and identify system vulnerabilities. This study examined risks – “no go” considerations - associated with in situ simulations focused on cardiac arrest in pregnancy and identified factors that could lead simulations to be canceled or postponed to ensure patient or staff safety.

RFID tags reduce restocking errors of anesthesia medications.

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Banks MA. Specialty Pharmacy Continuum. September 15, 2023.

Radiofrequency identification (RFID) devices are being used to improve processes in the operating room and prevent errors. This article examines the use of RFID tracking to build reliability into operating room anesthesia medication refiling process. The experience at one hospital found that the RFID process reduced errors, while increasing the task completion time.

Effects of work shift or shift length on radiation safety perception.

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Moore QT, Bruno MA. Radiol Technol. 2023;94(6):409-418.

Fostering a culture of safety is a key objective across all clinical areas, including radiology. This secondary analysis of survey data found that radiologists working night shifts and shifts exceeding 12 hours have poor perceptions of teamwork and of leadership actions concerning radiation safety.

Complications and Errors in Periodontal and Implant Therapy.

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Zucchelli G, Stefanini M, eds. Periodontol 2000. 2023;92(1):1-398.

Patient safety in dentistry shares common challenges with medicine and their emergence in a distinct care environment. This special issue covers a range of adverse events and treatment mistakes associated with periodontal procedures. Topics examined include human factors, implant placement and methodologic bias.

Implementation of medication reconciliation in outpatient cancer care.

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Powis M, Dara C, Macedo A, et al. BMJ Open Quality. 2023;12:e002211.

Medication reconciliation can help providers identify potential safety issues during medication administration. Based on interviews with stakeholders, this study examined medication reconciliation practices across Canadian cancer centers. Although a high proportion of the centers had a process for collecting best possible medication history (BPMH, 81%), implementation of a complete medication reconciliation process was uncommon. Stakeholders identified several barriers to implementation, including lack of resources and a lack of electronic health record interoperability across institutions, systems, and community pharmacies.

Effect of an emergency department process improvement package on suicide prevention: the ED-SAFE 2 cluster randomized clinical trial.

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Boudreaux ED, Larkin C, Vallejo Sefair A, et al. JAMA Psych. 2023;80:665-674.

Patients who present to the emergency department (ED) with suicidal ideation can benefit from ED-initiated interventions, but interventions can be difficult to implement and maintain. This research builds on a 2013 study, describing the quality improvement (QI) methods used to implement the Emergency Department Safety Assessment and Follow-up Evaluation 2 (ED-SAFE 2) trial. The QI approach was successful in reducing death by suicide and suicide-related acute care during the study period.

Voices from the Frontlines of Health Care Safety.

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Boston, MA; Betsy Lehman Center for Patient Safety; April 2023.

Well-told stories can motivate change. This video translates the experience of Massachusetts patients and family members with medical error for a broad audience. Clinicians also participate and share perspectives on problems in care systems that contribute to patient harm.

Death Inside Lemuel Shattuck Hospital: A Case Study on Medical Treatment for Persons with Mental Health Disabilities.

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Massachusetts Protection and Advocacy. Boston, MA: Disability Law Center; May 8, 2023.

Behavioral health patients present unique challenges in their care that can contribute to unintended harm. The analysis examines a delayed diagnosis, referral, and treatment of skin cancer that contributed to the death of a patient. Suggestions for improvement included conducting a root cause analysis to identify systemic problems, use of photography to track skin lesion progression, and implementation of a warm handoff process to improve staff communication.

Serious Reportable Events in Massachusetts.

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Fillo KT, Saunders K. Bureau of Health Care Safety and Quality, Department of Public Health. Boston, MA: Commonwealth of Massachusetts; 2023.

This reoccurring report compiles patient safety data collected by Massachusetts hospitals. The 2022 numbers document an increase in serious reportable events recorded in acute care hospitals, from 1430 the previous year to 1632. This presentation also includes events from ambulatory surgery centers. Older reports are also available.

Roadmap to Health Care Safety for Massachusetts.

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Massachusetts Healthcare Safety and Quality Consortium. Boston, MA: Betsy Lehman Center for Patient Safety; April 2023.

Collective engagement and focus are required to attain large system change. This plan centers on five goals to improve patient safety in Massachusetts: leadership and culture, operations and engagement, patient and family support, workforce wellbeing, and measurement and transparency. The document provides guidance for implementation of strategies targeting each goal to generate sustainable improvements.

Defining avoidable healthcare-associated harm in prisons: a mixed-method development study.

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Keers RN, Wainwright V, McFadzean J, et al. PLOS One. 2023;18:e0282021.

Prisons present unique challenges in providing, as well as in measuring, safe patient care. This article describes structures and processes within prison systems that may contribute to avoidable harm, such as limited staffing and security to travel to healthcare appointments. The result is a two-tier definition taking into consideration the unique context of prison healthcare.

The relationship between safety climate and safety performance: a review.

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Syed-Yahya SNN, Idris MA, Noblet AJ. J Safety Res. 2022;83:105-118.

A culture of safety is foundational to successful patient safety initiatives. This systematic review explored the relationship between safety climate and safety-related behaviors across various industries, including healthcare.

Maternal and Infant Health Inequality: New Evidence from Linked Administrative Data.

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Kennedy-Moulton K, Miller S, Persson P, et al. Cambridge, MA: National Bureau of Economic Research; 2022. NBER Working Paper No. 30693.

Unequal maternal care access and safety are known problems in communities of color. This report examines the alignment of economic stability with maternal and infant care quality and found parental income secondary to race and ethnicity as a damaging influence on care outcomes.

Using Machine Learning to Improve Patient Safety in the Home or Remote Setting for Adults.

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Feske-Kirby K, Whittington J, McGaffigan P. Boston, MA: Institute for Healthcare Improvement; 2022.

The potential of machine learning to improve care and safety is emerging as its application increases across health care. This report examines how machine learning can improve activities such as risk identification and prediction. It also discusses barriers to its use such as workload, expertise gaps, and system integration.

Involving patients and carers in patient safety in primary care: a qualitative study of a co-designed patient safety guide.

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Morris RL, Giles SJ, Campbell S. Health Expect. 2023;Jan 16.

Patient and caregiver engagement is an important strategy for improving the quality and safety of care. This qualitative study with 18 patients and/or caregivers explored perspectives on engagement in primary care. While participants were supportive of engagement in their care and safety, some expressed concerns regarding additional workload for patients. Participants also provided feedback on a patient safety guide for primary care (PSG-PC) and identified areas to embed the PSG-PC into routine interactions with primary care, particularly for individuals caring for a family member with complex or chronic health conditions.

Safer Together Survey: Advancing Patient and Workforce Safety

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Cambridge, MA: Institute for Healthcare Improvement: January 2023.

The National Steering Committee for Patient Safety (NSC) was formed to engage with the health care community to plan and prioritize patient safety work to generate improvements. This short survey seeks comments from the field to determine current interest and status in efforts aligned with the National Action Plan to Advance Patient Safety.

Tele-Rapid Response Team (Tele-RRT): the effect of implementing patient safety network system on outcomes of medical patients- a before and after cohort study.

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Balshi AN, Al-Odat MA, Alharthy AM, et al. PLoS ONE. 2022;17:e0277992.

Many hospitals have implemented rapid response teams (RRT) that are activated when a patient starts exhibiting prespecified criteria to prevent adverse outcomes. This before and after study compared nurse-activated RRT and automated activation. Non-invasive bedside sensors monitored patients’ vital signs and automatically sent alerts to the RRT based on prespecified clinical signs. Compared to the before period, there were lower rates of CPR, higher rates of successful CPR, shorter lengths of stay, and lower hospital mortality.

Accuracy in patient understanding of common medical phrases.

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Gotlieb R, Praska C, Hendrickson MA, et al. JAMA Netw Open. 2022;5:e2242972.

Ensuring patients understand their diagnosis and care plan is important to achieving optimal outcomes. However, patients routinely report not understanding what their provider has told them. In this study, adults were asked for their understanding of jargon clinicians regularly use (“negative” test results, NPO) and a corresponding statement without jargon (“you do not have an infection”, “nothing by mouth”). Some jargon was better understood (“negative”) than other jargon (“occult infection”). Participant demographics were not significantly associated with understanding jargon.

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