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.
Balestracci B, La Regina M, Di Sessa D, et al. Intern Emerg Med. 2023;18:275-296.
The COVID-19 pandemic extended face-masking requirements from healthcare providers to the general public and patients. This review summarizes the challenges mask wearing poses to the general public. Challenges include discomfort, communication issues, especially for people with hearing loss, and skin irritation. Despite these issues, the authors state the benefits outweigh the risks of masks and appropriate education may improve mask use.
Lefosse G, Rasero L, Bellandi T, et al. J Patient Saf Risk Manag. 2022;27:66-75.
Reducing healthcare-acquired infections is an ongoing patient safety goal. In this study, researchers used structured observations to explore factors contributing to healthcare-related infections in nursing homes in one region of Italy. Findings highlight the need to improve the physical care environment (e.g., room ventilation), handwashing compliance, and appropriate use of antibiotics.
Volpi E, Giannelli A, Toccafondi G, et al. J Patient Saf. 2021;17:e143-e148.
Medication errors are a common and significant causes of patient harm. This retrospective study examined regional prescription registry (RPR) data at a single Italian hospital at 4 comparison points, pre-admission, admission, hospitalization, and post-discharge. Researchers identified 4,363 discrepancies among 14,573 prescriptions originating from 298 patients with a mean age of 71.2 years. Approximately one third of the discrepancies (1,310) were classified as unintentional and the majority (62.1%) of those were found when comparing the prescriptions during the transition from hospital discharge and the 9-month follow up. The study points to the need for enhanced communication between hospitalists and primary care providers at the hospital-home interface.
La Regina M, Guarneri F, Romano E, et al. J Gen Intern Med. 2019;34:1314-1321.
Little is known about the safety of patients hospitalized in clinical units that do not correspond to their illness. In this systematic review, researchers looked at studies of patients placed in a nonpreferred location within the hospital because space in the clinically appropriate location was not available. The included studies also assessed multiple safety outcomes. They found no consistent effect on mortality or readmissions. Studies demonstrated increased use of rapid response teams when patients were not appropriately located, worse patient ratings of care quality, and a range of concerns about safety processes. The varying quality of the evidence has prompted the study team to begin a prospective observational study of appropriate unit placement and adverse events. A WebM&M commentary discussed an incident involving a patient who was boarded in the emergency department due to lack of room in the intensive care unit.
Rossi EG, Bellandi T, Picchi M, et al. Medicines (Basel). 2017;4.
Failure mode and effect analysis is a process used to prospectively identify error risk within a particular process. This study describes the application of failure mode and effect analysis to better understand the patient safety hazards associated with the practice of complementary medicine, including acupuncture and homeopathy.
Albolino S, Cook RI, O’Connor M. Cog Tech Work. 2006;9:131-137.
This study examined sensemaking within the context of the intensive care unit (ICU). The investigators used direct observation of ICU teams on rounds, in order to analyze how clinicians responded to the inherent complexity of ICU care, and to determine how clinicians attempted to avoid error and adverse outcomes. Clinicians used a variety of mechanisms to establish "cooperative conditioning," a shared understanding of the patient's acute needs and risks, which maximizes patient safety by establishing a common group culture and approach to decision making. The authors' approach is derived from the seminal study of sensemaking in organizations, an account of the Mann Gulch disaster.