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.
Liberati EG, Martin GP, Lamé G, et al. BMJ Qual Saf. 2023;Epub Sep 21.
“Safety cases” are used in healthcare and other industries to communicate the safety of a product, system, or service. In this study, researchers use the “safety case” approach to evaluate the safety of the Safer Clinical Systems program, which is designed to improve the safety and reliability of clinical pathways.
Herrera H, Wood D. Crit Care Nurs Clin North Am. 2023;35:347-355.
Children in the pediatric intensive care unit (PICU) require constant monitoring to detect early signs of worsening conditions. While these alerts from the monitors allow nurses and other staff to quickly intervene, alarm fatigue may set in, resulting in delayed responses. This article describes several causes for nonactionable or false alarms and makes recommendations to address them.
Lockery JE, Collyer TA, Woods RL, et al. J Am Geriatr Soc. 2023;71:2495-2505.
Potentially inappropriate medications (PIM) are a known contributor to patient harm in older adults. In contrast to most studies of PIM in patients with comorbid conditions or residing in hospitals or nursing homes, this study evaluated the impact of PIM use in community-dwelling older adults without significant disability. Participants with at least one PIM were at increased risk of physical disability and hospitalization over the study period (8 years) than those not taking any PIM. However, both groups had similar rates of death.
Martin G, Stanford S, Dixon-Woods M. BMJ. 2023;380:513.
The Francis report served as a call to action for improvement, following its recording of elements contributing to systemic failure within the British National Health Service (NHS). This commentary considers the overarching problems that still exist at the NHS and that listening, learning, and leadership involvement are core elements for driving and realizing lasting change throughout the system.
Westbrook JI, Li L, Raban MZ, et al. NPJ Digit Med. 2022;5:179.
Pediatric patients are particularly vulnerable to medication errors. This cluster randomized controlled trial examined the short- and long-term impacts of an electronic medication management (eMM) system implemented at one pediatric referral hospital in Australia. Findings suggest that eMM implementation did not reduce medication errors in the first 70 days of use, but researchers observed a decrease in medication errors one year after implementation, suggesting long-term benefits.
Dixon-Woods M, Martin G, eds. Cambridge, UK: Cambridge University Press; 2022-2023.
Improvement activities are complex initiatives that require synergistic actions by organizations to be sustained. This evolving series provides background, evidence, and discussion on interdisciplinary strategies known to affect quality and safety such as implementation science, collaboration, positive deviance, and culture change.
Soto C, Dixon-Woods M, Tarrant C. Arch Dis Child. 2022;107:1038-1042.
Children with complex medical needs are vulnerable to patient safety threats. This qualitative study explored the perspectives of parents with children living at home with a central venous access device (CVAD). Parents highlight the persistent fear of central line-associated blood stream infections as well as the importance of maintaining a sense of normalcy for their children.
The Centers for Medicare & Medicaid Services (CMS) provides individual and composite quality and safety ratings (i.e., star ratings) for hospitals and other healthcare facilities on its Care Compare website. This study evaluated three alternative methods for rating facilities and compared them to the CMS star ratings. Hospitals were frequently assigned a different star rating using the alternate methods, typically between adjacent star categories.
Stewardship interventions seek to optimize use of healthcare services, such as diagnostic tests or antibiotics. This article reports findings from a 14-site multidisciplinary collaborative evaluating pediatric intensive care unit (PICU) blood culture practices before and after implementation of a diagnostic stewardship intervention. Researchers found that rates of blood cultures, broad-spectrum antibiotic use, and central line-associated blood stream infections (CLABSI) were reduced postintervention.
Foster C, Doud L, Palangyo T, et al. Pediatr Qual Saf. 2021;6:e434.
Healthcare worker safety has been linked to overall safety culture. A pediatric hospital adapted patient safety event reporting infrastructure and definitions to worker safety reporting. Implementation of the worker safety reporting system reduced time from injury to reporting, identified safety gaps, and improved worker satisfaction with the reporting process.
Wiegmann DA, Wood LJ, Solomon DB, et al. J Healthc Risk Manag. 2021;41:31-46.
The Root Cause Analysis and Action (RCA2) framework supports the implementation of sustainable systems-based improvements after investigation of patient safety events. The authors provide an overview of the Human Factors Analysis and Classification System (HFACS), the Human Factors Intervention Matrix (HFIX), and a decision tool called FACES and describe how these tools can be integrated into the RCA2 framework to foster a comprehensive, human factors analysis of patient safety events and the identification of broader system interventions.
Liberati EG, Tarrant C, Willars J, et al. BMJ Qual Saf. 2021;30:444-456.
Maternal harm is a sentinel event and improving maternal safety is receiving increased attention in both policy and clinical settings. The researchers used qualitative methods to generate a new plain language framework identifying safe behaviors and practices in inpatient maternity units. Several synergistic features were identified including a commitment to safety culture; technical competence; teamwork, cooperation, and positive working relationships.
Wood LJ, Wiegmann DA. Int J Qual Health Care. 2020;32:438-444.
This article discusses the action hierarchy, which is a tool for generating corrective actions to improve safety and focuses on those recommendations relying less on human factors and more on systems change. The authors propose a multifaceted definition of ‘systems change’ and a rubric for determining the extent to which a corrective action addresses ‘systems change’ (‘systems change hierarchy’).
Westbrook JI, Li L, Raban MZ, et al. BMJ Qual Saf. 2021;30:320-330.
The researchers in this study directly observed nurses administering medications to pediatric patients to measure the association between double-checking and medication administration errors. When double-checking was mandated, the researchers did not find any significant association with medication errors. When double-checking was not mandated but was performed, medication administration errors were less likely to occur and were less severe, but the association was not significant. These findings raise questions about the benefits compared to single-checking.