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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 25 Results
Huth K, Hotz A, Emara N, et al. J Patient Saf. 2023;19:493-500.
The transition from hospital to home is a vulnerable time as patients may have changes in medications or care needs, or difficulties accessing follow up with an outpatient provider. To reduce adverse events (AE), rehospitalizations, and emergency department visits, this hospital developed a structured discharge bundle based on the I-PASS tool used for inpatient handoffs. AE, rehospitalizations, and emergency department visits were all reduced following implementation of the I-PASS bundle.
Mauskar S, Ngo T, Haskell H, et al. J Hosp Med. 2023;18:777-786.
Parents of children with medical complexity can offer unique perspectives on hospital quality and safety. Prior to their child's discharge, parents were surveyed about their child's care, medications, safety, and other concerns experienced during their stay. Parents reported experiencing miscommunication with the providers and providers seemingly not communicating with each other. They also reported inconsistency in care/care plans, unmet expectations, lack of transparency, and a desire for their expertise to be taken seriously.
Kieren MQ, Kelly MM, Garcia MA, et al. Acad Pediatr. 2023;Epub Jun 9.
Parents of children with medical complexity are an important part of the care team and can raise awareness of safety concerns. This study included parents of children with medical complexity who had reported safety concerns to members of their child's healthcare team. Parents whose concerns were validated and addressed felt increased trust in the team and hospital, whereas those whose concerns were invalidated or ignored felt disrespected and judged.
Kuzma N, Khan A, Rickey L, et al. J Hosp Med. 2023;8:316-320.
I-PASS, a structured hand-off tool, can reduce preventable adverse events during transitions of care. Previously published studies have shown that Patient and Family-Centered (PFC) I-PASS rounds reduced preventable and non-preventable adverse events (AE) in hospitalized children. This study presents additional analysis, comparing AE rates in children with complex chronic conditions (CCC) to those without. Results show a reduction in AE in both groups, with no statistically significant differences between the groups, suggesting PFC I-PASS may be generalizable to broader groups of patients without needing modification.
Mercer AN, Mauskar S, Baird JD, et al. Pediatrics. 2022;150:e2021055098.
Children with serious medical conditions are vulnerable to medical errors. This prospective study examined safety reporting behaviors among parents of children with medical complexity and hospital staff caring for these patients in one tertiary children’s hospital. Findings indicate that parents frequently identify medical errors or quality issues, despite not being routinely advised on how to report safety concerns.
Khan A, Parente V, Baird JD, et al. JAMA Pediatr. 2022;176:776-786.
Parent or caregiver limited English proficiency (LPE) has been associated with increased risk of their children experiencing adverse events. In this study, limited English proficiency was associated with lower odds of speaking up or asking questions when something does not appear right with their child’s care. Recommendations for improving communication with limited English proficiency patients and families are presented.
Khan A, Yin HS, Brach C, et al. JAMA Pediatr. 2020;174:e203215.
Language barriers between patients and providers is a potential contributor to adverse events. Based on a cohort of 1,666 Arabic-, Chinese-, English-, and Spanish-speaking parents of general pediatric and subspeciality patients 17 years and younger, this study examined the association between parents with limited comfort with English (LCE) and adverse events in hospitalized children. Compared with children of parents who expressed comfort or proficiency with English, children of parents who expressed LCE had significantly higher odds of experiencing an adverse event, including preventable events. Future research should focus on strategies to improve communication and safety for this vulnerable group of children.
Blaine K, Wright J, Pinkham A, et al. J Patient Saf. 2022;18:e156-e162.
… J Patient Saf … Medication errors are a serious problem   among hospitalized pediatric patients. … among children with complex medication conditions over a 12-month period and found that 6% of hospitalizations … occurred most frequently. Patients receiving baclofen (a skeletal muscle relaxant) were twice as likely to …
Khan A, Spector ND, Baird JD, et al. BMJ. 2018;363:k4764.
Patient engagement in safety takes many forms: patients may report unique safety incidents, encourage adherence to best medical practice, and coproduce improvement initiatives. Family-centered rounding in pediatrics invites families to express concerns, clarify information, and provide real-time input to the health care team. This pre–post study explored the safety impact of Patient and Family Centered (PFC) I-PASS rounds on 3106 admissions in pediatric units at 7 hospitals. Family-centered rounds reduced both preventable and nonpreventable adverse events. They also improved family experience without substantially lengthening rounding time. A past PSNet interview discussed the safety benefits of structured communication between health care providers and family members.
Stockwell DC, Landrigan CP, Toomey SL, et al. Hosp Pediatr. 2019;9:1-5.
The groundbreaking National Academy of Medicine report Unequal Treatment highlighted the pervasive nature of racial and ethnic disparities in United States health care. Racial and ethnic minorities experience more adverse events, including adverse drug events and hospital-acquired infections. Investigators used a pediatric global trigger tool to delineate disparities in safety events for a large, random sample of pediatric patients across 16 hospitals (4 hospitals in each US region). Latino children experienced nearly twice the rate of adverse events when compared with white children. Publicly insured children also had a higher adverse event rate. An accompanying editorial reviews study limitations and highlights the need to develop risk-prediction models for different types of adverse events.
Stockwell DC, Landrigan CP, Toomey SL, et al. Pediatrics. 2018;142:e20173360.
This study used a trigger tool (the Global Assessment of Pediatric Patient Safety) to examine temporal trends in adverse event rates at 16 randomly selected children's hospitals. Adverse event rates did not significantly change at either teaching or nonteaching hospitals from 2007 to 2012. Interestingly, nonteaching hospitals had lower error rates than teaching facilities, although the increased complexity of patients at teaching hospitals may account for this finding. The results of this study mirror those of a similar study conducted in adult hospitals from 2002 to 2007. An accompanying editorial notes that quality improvement collaboratives have achieved reductions in hospital-acquired conditions at children's hospitals and speculates that these discordant findings could be due to the fact that trigger tools are able to detect a broader range of adverse events and thus may provide a more accurate picture of safety. A WebM&M commentary discussed a preventable medication error at a children's hospital.
Haffajee RL, Mello MM, Zhang F, et al. Health Aff (Millwood). 2018;37:964-974.
… … Health Aff (Millwood) … The opioid epidemic is a well-recognized national patient safety issue. High-risk … the end of 2014, all four states with PDMPs demonstrated a greater reduction in the average amount of … with states without these programs. One state demonstrated a decrease in the percentage of people who filled an opioid …
Khan A, Coffey M, Litterer KP, et al. JAMA Pediatr. 2017;171:372-381.
Detecting adverse events remains a challenge across health care settings. This prospective study conducted in multiple pediatric inpatient settings used medical record review, clinician reports, and hospital incident reports to identify adverse events. Investigators compared adverse events detected with these mechanisms to adverse events identified through interviews with parents and caregivers of pediatric patients. As with previous studies, two physicians reviewed all incidents and rated the severity and preventability of all incidents. About half the incidents reported by family members were determined to be safety concerns; fewer than 10% of these incidents were felt to be preventable adverse events. Family-reported error rates were similar to error rates drawn from actively eliciting error reports from clinicians. Families were able to identify preventable adverse events that were not detected by any other method. Error rates calculated from hospital incident reports were much lower than those drawn from either clinician or family reports, consistent with prior studies. These results demonstrate that families can identify otherwise undetected adverse events and their input should be elicited in safety surveillance systems.
Toomey SL, Peltz A, Loren S, et al. Pediatrics. 2016;138.
Readmissions to the hospital are considered a marker of patient safety, and hospitals with high readmission rates are subject to reduced Medicare reimbursements. The extent to which readmissions are preventable remains controversial. Investigators examined 300 pediatric readmissions at a single hospital with input from inpatient providers, primary care providers, patients, family members, and medical records. They determined that approximately 30% of readmissions were preventable. Both patient-related factors such as parental anxiety and hospital-related factors such as hospital-acquired conditions contributed to preventable readmissions. The authors emphasize the importance of interviewing patients and family members as well as medical providers to better characterize the preventability of readmissions. They suggest that identifying factors associated with preventable readmissions will lead to readmission reduction strategies. Multiple strategies targeting the different contributing factors will likely be needed. A past PSNet interview reflected on the challenge of preventing readmissions.
Khan A, Rogers JE, Forster CS, et al. Hosp Pediatr. 2016;6:319-29.
This survey study identified significant communication gaps between parents of hospitalized children and the resident physicians caring for them overnight. Although both parents and physicians rated communication highly, there were differences in parent and physician understanding of the reason for admission, overall plan, and overnight plan, particularly for children with more complex illness. This demonstrates the gap between perceptions of communication and shared understanding.
Khan A, Furtak SL, Melvin P, et al. JAMA Pediatr. 2016;170:e154608.
Whether patient and family understanding of safety issues aligns with standard definitions of medical errors is unclear. In this study, parents of pediatric inpatients were asked if their children experienced any safety incidents during hospitalization. Physician reviewers evaluated parents' reports and designated incidents as errors or quality issues or excluded them. Just under 10% of respondents reported an incident, and 62% of these were confirmed by the study team as medical errors, with the remainder considered either quality issues or exclusions. Consistent with prior studies, many of the confirmed errors were not captured in the medical record. This work demonstrates that allowing patients and families to report safety concerns can identify previously unknown errors. A recent PSNet perspective calls for enhanced patient engagement in safety.