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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 - 16 of 16 Results
Sosa T, Mayer B, Chakkalakkal B, et al. Hosp Pediatr. 2022;12:37-46.
Many medications and medical devices can result in preventable harm in pediatric patients. This article describes one hospital’s efforts to implement explicit, structured processes and huddles to increase situational awareness regarding high-risk therapies among the care team and family members. After implementation, the percentage of electronic health record (EHR) alerts correctly describing high-risk therapies increased from 11% to 96%.
Sosa T, Sitterding M, Dewan M, et al. Pediatrics. 2021;148:e2020034603.
Situational awareness during critical incidents is a key attribute of effective teams. This article describes the development of a situational awareness model, which included involving families and the interdisciplinary team in huddles, a shared mental model checklist, and an electronic health record (EHR) situational awareness navigator. Use of this new model decreased emergency transfers to the ICU and improved process measures, such as improved risk recognition before medical response team activation.
Britto MT, Fuller SC, Kaplan HC, et al. BMJ Qual Saf. 2018;27.
The National Academy of Sciences has advocated for a Learning Healthcare System in which patients are engaged in shared decision-making to choose evidence-based, high-quality care. However, realizing the vision of a system that improves over time as a direct result of learning captured from patient care has proved challenging. This study describes the development and implementation of a network organizational model for learning health care networks. The authors note that several organizations following such a model (e.g., the Solutions for Patient Safety Network) have been successful in improving patient outcomes. While the networks described focus on pediatric care, they suggest that the same principles and processes could be applied to improve outcomes for other populations. A past PSNet perspective discussed the use of complex health care data to improve patient care.
Walsh KE, Harik P, Mazor KM, et al. Med Care. 2017;55:436-441.
Determining the severity of harm or potential harm is a challenge in patient safety. Investigators asked physicians, nurses, and pharmacists to rate the severity of harm for specific adverse events including falls, health care–associated infections, pressure ulcers, and blood product errors. The authors recommend using two raters to determine harm in order to achieve reliable estimates.
Weiss BD, Scott M, Demmel K, et al. J Oncol Pract. 2017;13:e329-e336.
Prescribing and administering chemotherapy involves complex processes that are vulnerable to error. This study discussed how improvement efforts, including standardization and minimizing interruptions, led to a decrease in the rate of chemotherapy errors reaching patients at a large urban academic pediatric medical center.
Warrick D, Gonzalez-del-Rey J, Hall D, et al. Hosp Pediatr. 2015;5:127-33.
This study details how improvement science methods were used to augment the quality of handoffs for patients being transferred from the pediatric intensive care unit to the general floor. The authors found enhanced documentation of both verbal and written handoffs after implementation of a quality improvement intervention.
Brady PW, Zix J, Brilli RJ, et al. BMJ Qual Saf. 2015;24:203-211.
Allowing families to activate medical emergency teams (METs) may aid in the early detection of clinical deterioration. However, physicians have expressed concerns that families do not understand when an MET is necessary and that this responsibility could present an undue stress on family members. This study reports on the experience of family-activated MET calls over a 6-year period at an academic children's hospital. There were 83 family-activated MET calls, representing less than 3% of all MET responses at this hospital. Families most frequently requested METs for concerns regarding clinical deterioration, but less than one-quarter of these calls resulted in patients being transferred to an intensive care unit, compared to 60% of clinician-activated METs. Since families called METs only between one to two times per month, the program was not felt to pose a substantial burden. The authors also point out that some family-activated METs identified other clinically relevant information that may not have otherwise been shared with the primary clinical team, as well as important communication issues that could have led to adverse events.
Brady PW, Muething S, Kotagal U, et al. Pediatrics. 2013;131:e298-308.
Lack of appropriate situational awareness is an important source of diagnostic errors. One particularly dramatic outcome of poor situational awareness is an unanticipated transfer to an intensive care unit (ICU) due to failure to identify and treat clinical deterioration in a hospitalized patient. This study aimed to design a novel care system at a large pediatric hospital that would improve situational awareness of clinically deteriorating patients and ultimately decrease serious safety events. The team utilized a number of overlapping interventions, including proactive risk identification, frequent multidisciplinary huddles, and implementation of mechanisms that promote a continuous learning organization. This comprehensive system was associated with an almost 50% reduction in "unrecognized situation awareness failures events" (UNSAFE) leading to ICU transfer.
Kirkendall E, Kloppenborg E, Papp J, et al. Pediatrics. 2012;130:e1206-14.
The Institute for Healthcare Improvement's (IHI) Global Trigger Tool is a well-established sampling method for measuring adverse events in adult patients. Previously, a modified pediatric-focused tool aimed at identifying medication-related errors was developed; however, the full IHI trigger tool has never been formally evaluated in a pediatric setting. In this retrospective chart review study, the Global Trigger Tool identified a higher rate of harm (2 to 3 times) than that seen in previous pediatric research. Dr. Paul Sharek discusses trigger tools and other approaches for measuring adverse event rates in an AHRQ WebM&M perspective.
White CM, Schoettker PJ, Conway PH, et al. BMJ Qual Saf. 2011;20:372-80.
Medication reconciliation is necessary to reduce preventable medication errors, but despite much research, no consensus exists on how the process should be performed in either the inpatient or outpatient setting. This study, conducted at a children's hospital, demonstrates how accurate medication reconciliation can be achieved through establishing a culture of safety and rigorously applying quality improvement principles. Although the hospital had an existing electronic health record and computerized provider order entry system, a reliable medication reconciliation process was not achieved until existing processes were thoroughly analyzed, failure modes were determined, and rapid cycle tests of change were conducted. As medication reconciliation will be reinstated as a National Patient Safety Goal in July 2011, this article provides a useful blueprint for organizations tackling this difficult problem.