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.
Latimer S, Hewitt J, de Wet C, et al. J Clin Nurs. 2023;32:1276-1285.
Medication reconciliation at hospital discharge has become a mainstay of patient safety efforts with most of the focus on pharmacist involvement. Focus groups of hospital nurses were conducted to elicit their perspectives on their role in medication reconciliation. Three themes emerged: nurses' role involves chasing, checking, and educating; burden of undertaking medication reconciliation at hospital discharge; team collaboration and communication in medication reconciliation.
Gillespie BM, Harbeck EL, Rattray M, et al. Int J Surg. 2021;95:106136.
Surgical site infections (SSI) are a common, yet largely preventable, complication of surgery which can result in increased length of stay and hospital readmission. In this review of 57 studies, the cumulative incidence of SSI was 11% in adult general surgical patients and was associated with increased length of stay (with variation by types of surgery).
Medication safety, particularly among older adults who may have complex medication regimens, is an ongoing safety concern. This study explored medication safety behaviors among young-old (65-74 years), middle-old (75-84 years) and old-old (>85 years) adults. The authors found that older adults are willing to engage in medication safety behaviors, but that preferred behaviors (e.g., verbal behaviors, self-administering medication, reviewing medication charts) differed among the age groups.
Wood C, Chaboyer W, Carr P. Int J Nurs Stud. 2019;94:166-178.
Early detection of patient deterioration remains an elusive patient safety target. This scoping review examined how nurses employ early warning scoring systems that prompt them to call rapid response teams. Investigators identified 23 studies for inclusion. Barriers to effective identification and treatment of patient deterioration included difficulty implementing early warning score systems, overreliance on numeric risk scores, and inconsistent activation of rapid response teams based on early warning score results. They recommend that nurses follow scoring algorithms that calculate risk for deterioration while supplementing risk scoring with their clinical judgment from the bedside. A WebM&M commentary highlighted how early recognition of patient deterioration requires not only medical expertise but also collaboration and communication among providers.
Following surgery under general anesthesia, a boy was extubated and brought to postanesthesia care unit (PACU). Due to the patient's age and length of the surgery, the PACU anesthesiologist ordered continuous pulse-oximetry monitoring for 24 hours. Deemed stable to leave the PACU, the boy was transported to the regular floor. When the nurse went to place the patient on pulse oximetry, she realized he was markedly hypoxic. She administered oxygen by face mask, but he became bradycardic and hypotensive and a code blue was called.
Gillespie BM, Harbeck EL, Lavin J, et al. BMJ Open Qual. 2018;7:e000362.
Checklists like the Universal Protocol are a widely accepted strategy for reducing wrong site, wrong procedure, and wrong patient surgeries. The authors describe a campaign that improved checklist participation and completion in an academic hospital in Australia. A PSNet interview with Lucian Leape explored the challenges of achieving robust and universal use of checklists.
Ringdal M, Chaboyer W, Ulin K, et al. BMC Nurs. 2017;16:69.
This qualitative study of hospitalized patients in Sweden found that patients expressed interest in engaging in their care. Themes included shared decision-making and increasing patient understanding of health conditions. Patients also expressed concern about the power dynamic between patients and providers and uncertainty about how to best participate in their own hospital care.
Gillespie BM, Withers TK, Lavin J, et al. Patient Saf Surg. 2016;10:3.
Analyzing approximately 35 hours of field observations, these researchers identified various interlinked factors, including team attributes, communication strategies, and checking processes, that affect whether surgical teams participated in safety checks.
Context is an important component of successful checklist implementation initiatives. This review explores the evidence to determine how contextual and implementation factors influence compliance and sustainability of checklist use. The authors found that sustained use of checklists was discipline-specific and was more successful when clinicians were engaged in designing and implementing the checklists.
Gardiner TM, Marshall AP, Gillespie BM. Aust Crit Care. 2015;28:226-34.
Structured information transfer can reduce communication errors and augment the handoff process. Exploring standardized handovers between the operating room and the intensive care unit, this commentary found the evidence base to be limited and calls for more studies to expand the understanding of how structured communication methods affect postoperative handover.
Massey D, Aitken LM, Chaboyer W. Intensive Crit Care Nurs. 2015;31:83-90.
This study of an after-hours rapid response team found that the team was not always activated as intended. More unplanned admissions to intensive care were identified following rapid response implementation, possibly due to enhanced surveillance for clinical deterioration. Under-utilization of rapid response may account for mixed results in improving patient safety.
Gillespie BM, Chaboyer W, Thalib L, et al. Anesthesiology. 2014;120:1380-9.
In contrast to a recent study that showed no change in postoperative morbidity and mortality following checklist adoption, this systematic review explored the evidence and found that checklist implementation was linked to a reduction in overall surgical complications. The authors recommend that checklists be used with other interventions to augment safety.
Gillespie BM, Chaboyer W, Fairweather N. AORN J. 2012;95:576-90.
Interruptions were associated with an increased risk of miscommunication between team personnel during surgical procedures. Teams that had limited experience working together seemed to be particularly vulnerable to miscommunications.
Gillespie BM, Chaboyer W, Fairweather N. BMJ Qual Saf. 2012;21:3-12.
This qualitative study, based on direct observation of 160 surgical procedures, found that communication breakdowns were significantly correlated with deviations from the expected length of the procedure.
Gillespie BM, Chaboyer W, Murray P. AORN J. 2010;92:642-57.
This review analyzed 12 studies focused on team training in surgical settings, and found before-and-after implementation improvements in team practices and complication rates. However, similar to a past review, the authors highlight limitations in study design and the need for additional research on team training strategies.
Bost N, Crilly J, Wallis M, et al. Int Emerg Nurs. 2010;18:210-20.
This review found that handoff errors are common between ambulance personnel and the emergency department, and there is a need for standardization of handoff responsibilities and development of structured handoff protocols.