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.
Tariq MB, Ali I, Salazar‐Marioni S, et al. J Am Heart Assoc. 2023;12:e029830.
Delayed diagnosis and treatment of stroke leads to adverse patient outcomes. This cross-sectional study identified gender disparities in the treatment of patients with large vessel occlusion (LVO) acute ischemic stroke (AIS), with women being less likely to be routed directly to comprehensive stroke centers compared with men, despite having more significant stroke syndromes.
Schilling S, Armaou M, Morrison Z, et al. PLoS ONE. 2022;17:e0272942.
Effective teamwork is critical in acute and intensive care settings. This systematic review of reviews and thematic analysis identified four key factors that frame the evidence on interprofessional teams in acute and intensive care settings – (1) team internal procedures and dynamics, such as cohesion, organizational culture, and leadership influence; (2) communicative processes; (3) organizational and team-extrinsic influences, such as team composition, hierarchy, and interprofessional dynamics, and; (4) team outcomes, including both patient and staff outcomes.
Beed M, Hussain S, Woodier N, et al. J Patient Saf. 2022;18:e652-e657.
… thematic areas for potential improvement were identified (e.g., failure to rescue, staffing concerns, equipment/drug … to improve high-risk patient safety event outcomes. … Beed M, Hussain S, Woodier N, et al. A 6-year thematic review of …
Cooper A, Carson-Stevens A, Cooke M, et al. BMC Emerg Med. 2021;21:139.
… . This study examined diagnostic errors after introducing a new healthcare service model in which emergency departments … and communication between GP and ED services. … Cooper A, Carson-Stevens A, Cooke M, et al. Learning from diagnostic errors to improve patient …
Jaam M, Naseralallah LM, Hussain TA, et al. PLoS One. 2021;16:e0253588.
Including pharmacists can improve patient safety across the medication prescribing continuum. This review identified twelve pharmacist-led educational interventions aimed at improving medication safety. The phase, educational strategy, patient population, and audience varied across studies; however most showed some reductions in medication errors.
Aftab H, Shah SHH, Habli I. Stud Health Technol Inform. 2021;281:659-663.
Patients are increasingly using the internet and conversational agents (CAs) like Siri, Alexa, and Google to find answers to their healthcare questions. Investigators used these CAs to detect errors and failures in calculating correct insulin doses. Failure classes include misunderstanding and misrecognition of words. Potential failures must be considered before deployment of CAs in safety-critical environments.
Patients with chronic health needs, including those with cancer, and their providers face numerous challenges during the COVID-19 pandemic. Survey results from 356 health care centers across 54 countries indicate that the impact of the COVID-19 pandemic on cancer care is widespread. Many centers reported challenges in delivering care, reduction in services, lack of personal protective equipment, staffing shortages, and limited access to medications. Respondents also reported potential patient harm due to interruptions in cancer-specific and non-cancer care.
Naseralallah LM, Hussain TA, Jaam M, et al. Int J Clin Pharm. 2020;42:979-994.
Pediatric patients are particularly vulnerable to medication errors. In this systematic review, the authors evaluated the evidence on the effectiveness of clinical pharmacist interventions on medication error rates in hospitalized pediatric patients. Results of a meta-analysis found that pharmacist involvement was associated with a significant reduction in the overall rate of medication errors in this population.
Hussain F, Cooper A, Carson-Stevens A, et al. BMC Emerg Med. 2019;19:77.
… to the diagnostic errors: insufficient assessment (e.g., failure to order imaging or refer patients when … to address these contributors are briefly discussed. … HussainF, Cooper A, Carson-Stevens A, et al. BMC Emerg Med. 2019 Dec …
Hussain MI, Reynolds TL, Zheng K. J Am Med Inform Assoc. 2019;26:1141-1149.
This systematic review examined the override rates of several different clinical decision support approaches. Researchers conclude that role tailoring—the provision of different alerts to prescribers versus pharmacists—was the most successful method to reduce alert fatigue. They recommend redesigning decision support to reduce alert fatigue.
Hussain A, Oestreicher J. Surv Ophthalmol. 2018;63:119-124.
Flawed decision-making influences the effectiveness of care on many levels. This review discusses cognitive shortcuts and biases that contribute to diagnostic error. The authors explore how and when these biases occur in opthalmology. Strategies to avoid decision-making errors include cognitive debiasing and heuristic examination.
Nanji KC, Seger DL, Slight SP, et al. J Am Med Inform Assoc. 2018;25:476-481.
… Assoc … Medication-related clinical decision support is a ubiquitous component of computerized provider order entry … Although this single institution investigation of a homegrown, older CPOE system may not be generalizable to … alert fatigue compromises patient safety . A previous WebM&M commentary discussed the challenges of designing safe CPOE. …
Savage C, Gaffney A, Hussain-Alkhateeb L, et al. Int J Health Care Qual. 2017;29:853-860.
This Swedish pediatric surgery team employed crew resource management training, which included checklists, communication training, and workflow redesign. The pre–post analysis showed sustained improvements in safety culture, checklist adherence, communication quality, and unplanned returns to surgery after laparoscopic appendectomy. Although this study design cannot control for secular trends, few crew resource management analyses include patient outcomes or such lengthy follow-up.
The ability of staff and clinicians to report concerns about patient safety is key to preventing errors and improving safety. This review explores the evidence on positive and negative consequences of whistleblowing to help guide development of future whistleblowing policies.
Liu F, Abdul-Hussain S, Mahboob S, et al. Int J Clin Pharm. 2014;36:827-34.
Elderly patients are particularly vulnerable to adverse drug events. This analysis found that the majority of medication information leaflets were difficult for older patients to read and interpret. Similar problems have been found with medication labels.
Al-Qahtani S, Al-Dorzi HM, Tamim HM, et al. Crit Care Med. 2013;41:506-17.
This Saudi Arabian study describes a rapid response team implementation consisting of an intensive care physician, critical care nurse, and respiratory therapist. Over a 3-year period, the introduction of the team was associated with fewer cardiopulmonary arrests and improved hospital mortality.