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.
Salmon PM, Hulme A, Walker GH, et al. Ergonomics. 2023;66:644-657.
Systems thinking concepts are used by healthcare organizations to encourage learning from failures and identifying solutions to complex patient safety problems. This article outlines a refined and validated set of systems thinking tenets and discusses how they can be used to proactively identify threats to patient safety.
Feather C, Appelbaum N, Darzi A, et al. BMJ Qual Saf. 2023;32:357–368.
… BMJ Qual Saf … Requiring a prescriber to include an indication for a medication can reduce the risk of wrong-patient orders and … privacy or alert fatigue . … Feather C, Appelbaum N, Darzi A, et al. Indication documentation and indication-based …
Kelly D, Koay A, Mineva G, et al. Public Health. 2022;214:50-60.
Natural disasters and other public health emergencies (PHE), such as the COVID-19 pandemic, can dramatically change the delivery of healthcare. This scoping review identified considerable research examining the relationship between public health emergencies and disruptions to personal medication practices (e.g., self-altering medication regimens, access barriers, changing prescribing providers) and subsequent medication-related harm.
Averill P, Vincent CA, Reen G, et al. Health Expect. 2023;26:51-63.
Patient safety research on inpatient psychiatric care is expanding, but less is known about outpatient mental health patient safety. This review of safety in community-based mental health services revealed several challenges, including defining preventable safety events. Additionally, safety research has focused on harm caused by the patient instead of harm caused by mental health services, such as delays in access or diagnosis.
Gogalniceanu P, Karydis N, Costan V-V, et al. J Am Coll Surg. 2022;235:612-623.
Safety strategies from high-reliability industries such as aviation and nuclear power are frequently adapted for healthcare. In this study, pilots described crisis preparedness strategies, which surgical safety experts then developed into a framework consisting of six behavioral interventions: anticipate threats, briefing, checklists, drill rehearsal, individual and team empowerment, and debriefing. An earlier study by the authors describes the second phase in managing crisis: crisis recovery.
Sutherland A, Jones MD, Howlett M, et al. Drug Saf. 2022;45:881-889.
Intravenous (IV) medication smart pumps can improve medication administration, but usability issues can compromise safety. This article outlines strategic recommendations regarding the implementation of smart pump technology to improve patient safety. Recommendations include standardization of infusion concentrations, improving drug libraries using a human-centered approach, and increasing stakeholder engagement.
Jones MD, Clarke J, Feather C, et al. Ann Pharmacother. 2021;55:1333-1340.
… medicine. Findings suggest that deviations play a crucial role in intravenous medication administration … online injectable medicine guideline. … Jones MD, Clarke J, Feather C, et al. Use of pediatric injectable medicines … and associated medication administration errors: a human reliability analysis. Ann Pharmacother. …
Chaudhry NT, Franklin BD, Mohammed S, et al. Pharmacy (Basel). 2021;9:198.
… mechanisms, and barriers for SUD. … Chaudhry NT, Franklin BD, Mohammed S, Benn J. The secondary use of data to support medication safety in the hospital setting: a systematic review and narrative synthesis. Pharmacy …
Ocloo J, Garfield S, Franklin BD, et al. Health Res Policy Syst. 2021;19:8.
… training, and power dynamics. … Ocloo J, Garfield S, Franklin BD, et al. Exploring the theory, … involvement across health, social care and patient safety: a systematic review of reviews. Health Res Policy Syst. …
Jones MD, McGrogan A, Raynor DK, et al. BMJ Qual Saf. 2021;2021:17-26.
This study compared the frequency of intravenous (IV) medication errors using the current National Health Service Injectable Medicines Guide (IMG) versus revised IMG-based user-testing, which included such revisions as provision of equations and tables to support rate calculations. Findings indicate that user-tested guidelines led to fewer medication errors, less time to prepare and administer IV medications, and increased staff confidence.
Storesund A, Haugen AS, Flaatten H, et al. JAMA Surg. 2020;155:562-570.
This study assessed the impact of combined use of two surgical safety checklists on morbidity, mortality, and length of stay – the Surgical Patient Safety System (SURPASS) is used to address preoperative and postoperative care, and the World Health Organization surgical safety checklist (WHO SSC) is used for perioperative care. In addition to existing use of the WHO SSC, the SURPASS checklist was implemented in three surgical departments in one tertiary hospital in Norway. Results demonstrated that combined use of these checklists was associated with reduced complications reoperations, and readmissions, but combined use did not impact mortality or length of stay.
Wæhle HV, Haugen AS, Wiig S, et al. BMC Health Serv Res. 2020;20.
This qualitative study examined how perioperative teams integrate surgical safety checklists into daily surgical practice and existing risk management strategies. Perceived usefulness was the primary factor associated with use (69%); nurse anesthetists and anesthesiologists were more likely than other provider types to express that their existing safety protocols were sufficient and that elements of the checklist are redundant. The perception of usefulness was found to have considerable impact on checklist execution and communication, and the tool is most effective when it is an integrated part of the multidisciplinary risk management strategy.
Using a participatory action research approach, this study evaluated a smartphone app intended to empower surgical patients and caregivers to help optimize their care. Forty-two patients were enrolled in the study and they underwent a variety of different surgical procedures. Most patients felt that app was useful and informative (79%), was easy to use (74%) and helped participants to ask better questions (76%) and feel more involved in conversations about their care. However, almost half of participants (48%) were unsure about how the app could affect safety, citing that safety was the responsibility of the clinical staff alone rather than patients.
Geeson C, Wei L, Franklin BD. International Journal of Pharmacy Practice. 2020.
… errors continue throughout the hospital stay, indicating a need for ongoing pharmacy review. … Geeson C, Wei L, Franklin BD. Analysis of pharmacist-identified … Kingdom hospitals: a prospective observational study. Int J Pharm Pract. 2020. Epub 2020 Feb 13. doi: …
Appelbaum N, Clarke J, Feather C, et al. BMJ Open. 2019;9:e032686.
While medication errors during paediatric resuscitation are considered common, little information about the processes that contribute to them has been gathered. This prospective observational study in a large English teaching hospital describes the incidence, nature and severity of medication errors made by 15 teams, each comprised of two doctors and two nurses, during simulated paediatric resuscitations. Clinically significant errors were made in 11 of the 15 cases, most due to discrepancies in drug ordering, preparation and administration. The authors recommend additional research into new approaches to protecting patients in paediatric emergency settings.
Geeson C, Wei L, Franklin BD. BMJ Qual Saf. 2019;28:645-656.
… … This article describes the development and validation of a scoring tool to identify patients most at risk for adverse … consultation during hospitalization. … Geeson C, Wei L, Franklin BD. Development and performance evaluation of the Medicines Optimisation Assessment Tool (MOAT): a prognostic model to target hospital pharmacists' input to …