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.
Murphy DR, Zimolzak AJ, Upadhyay DK, et al. J Am Med Inform Assoc. 2023;30:1526-1531.
Measuring diagnostic performance is essential to identifying opportunities for improvement. In this study, researchers developed and evaluated two electronic clinical quality measures (eCQMs) to assess the quality of colorectal and lung cancer diagnosis. Each measure used data from the electronic health record (EHR) to identify abnormal test results, evidence of appropriate follow-up, and exclusions that signified unnecessary follow-up. The authors describe the measure testing results and outline the challenges in working with unstructured EHR data.
Ward CE, Taylor M, Keeney C, et al. Prehosp Emerg Care. 2023;27:263-268.
Weight-based calculation errors and lack of weight documentation can lead to medication errors in pediatric patients. This analysis of Maryland emergency medical services (EMS) data including children who received a weight-based medication found that weight documentation was associated with a small but significantly lower rate of medication dose errors, particularly among infants and for epinephrine and fentanyl doses.
Normalization of deviance refers to the wide adoption of poor practices despite associated safety hazards. This article discusses how normalization of deviance threatens high-reliability and outline strategies to mitigate normalization of deviance in operating rooms (ORs).
Tan J, Ross JM, Wright D, et al. Jt Comm J Qual Patient Saf. 2023;49:265-273.
Wrong-site surgery is considered a never event and can lead to serious patient harm. This analysis of closed medical malpractice claims on wrong-site surgery between 2013 and 2020 concluded that the risk of wrong-site surgery increases with spinal surgeries (e.g., spinal fusion, excision of intervertebral discs). The primary contributing factors to wrong-site surgery was failure to follow policy or protocols (such as failure to follow the Universal Protocol) and failure to review medical records.
Gross TK, Lane NE, Timm NL, et al. Pediatrics. 2023;151:e2022060971-e2022060972.
Emergency room crowding is a persistent factor that degrades safety for patients of all ages. This collection provides background, best practices, and recommendations to reduce emergency department crowding and its negative impact on pediatric care. The publications examine factors that influence crowding and improvement at the input, departmental, and hospital/outpatient stages of emergency care.
Halligan D, Janes G, Conner M, et al. J Patient Saf. 2023;19:143-150.
Reducing low-value tests and treatments has been a focus of patient safety efforts, but less attention has been focused on low-value patient safety practices (PSP). This study describes the concept of “safety clutter” and understanding which PSP are of low-value, ineffective, and could be discontinued. Frequently cited PSP included paperwork, duplication, and intentional rounding.
Holland R, Bond CM, Alldred DP, et al. BMJ. 2023;380:e071883.
Careful medication management in long-term care residents is associated with improved hospital readmission rates and reduced fall rates. In the UK, pharmacist independent prescribers (PIP) can initiate, change, or monitor medications, and this cluster randomized controlled trial evaluated the effect of PIPs on fall rates. After six months of PIP involvement, fall rates (the primary outcome) were not statistically different than the usual care group, although drug burden was reduced.
Joseph MM, Mahajan P, Snow SK, et al. Pediatrics. 2022;150:e2022059673.
Children with emergent care needs are often cared for in complex situations that can diminish safety. This joint policy statement updates preceding recommendations to enhance the safety of care to children presenting at the emergency department. It expands on the application of topics within a high-reliability framework focusing on leadership, managerial factors, and organizational factors that support safety culture and workforce empowerment to support safe emergency care for children.
Wright DJ, Gabbay J, Le May A. BMJ Qual Saf. 2022;31:450-461.
… BMJ Qual Saf … Healthcare staff use a variety of skills to implement quality improvement and … education , and the ability to consider local context. … WrightD, Gabbay J, Le May A. Determining the skills needed by …
… J Patient Saf … Hospitals employ a variety of strategies to prevent inpatient falls . Based on … of serious harm resulting from a fall. … Saleem J, Sarma D, Wright H, et al. Multifactorial interventions to reduce …
Gionfriddo MR, Duboski V, Middernacht A, et al. PLoS ONE. 2021;16:e0260882.
… PLoS ONE … Medication reconciliation is a widely used strategy to reduce medication adverse events in … study were to identify behaviors indicative of obtaining a best possible medication history, barriers to medication … integration). … Gionfriddo MR, Duboski V, Middernacht A, et al. A mixed methods evaluation of medication …
Sittig DF, Sengstack P, Singh H. JAMA. 2022;327:719-720.
… and used correctly . This commentary discusses elements of a guidance package to enhance EHR safety through a 5-step assessment process. … Sittig DF, Sengstack P, Singh H. Guidelines for US hospitals …
Schiff GD, Volodarskaya M, Ruan E, et al. JAMA Netw Open. 2022;5:e2144531.
Improving diagnosis is a patient safety priority. Using data from patient safety incident reports, malpractice claims, morbidity and mortality reports, and focus group responses, this study sought to identify “diagnostic pitfalls,” defined as clinical situations vulnerable to errors which may lead to diagnostic errors. The authors identified 21 generic diagnostic pitfall categories involving six different aspects of the clinical interaction – diagnosis and assessment, history and physical, testing, communication, follow-up, and other pitfalls (e.g., problems with inappropriate referral, urgency of the clinical situation not appreciated). The authors suggest that these findings can inform education and quality improvement efforts to anticipate and prevent future errors.
… JAMA … Assessment is a valuable activity to guide safety strategy articulation and … ensure the viability of the process to improve safety. … Sittig DF, Singh H. Policies to promote shared responsibility …
Khawagi WY, Steinke DT, Carr MJ, et al. BMJ Qual Saf. 2022;31:364-378.
Patient safety indicators (PSIs) can be used to identify potential patient safety hazards. Researchers used the Clinical Practice Research Datalink GOLD database to examine prevalence, variation, and patient- and practice-level risk factors for 22 mental health-related PSIs for medication prescribing and monitoring in primary care. The authors found that potentially inappropriate prescribing and inadequate medication monitoring commonly affected patients with mental illness in primary care.
Vaghani V, Wei L, Mushtaq U, et al. J Am Med Inform Assoc. 2021;28:2202-2211.
Based on the Safer Dx and SPADE frameworks, researchers applied a symptom-disease pair-based electronic trigger (e-trigger) to identify patients hospitalized for stroke who had been previously discharged from the emergency department with a diagnosis of headache or dizziness in the preceding 30 days. Analyses show that the e-trigger identified missed diagnoses of stroke with a modest positive predictive value.