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.
McComb SA, Lemaster M, Henneman EA, et al. J Patient Saf. 2017;13:237-242.
Interprofessional collaboration is a cornerstone of safe patient care. Researchers surveyed inpatient nurses and physicians and found discordant perceptions of each others' roles as well as lower levels of trust in the other profession when compared to their own. Fostering a shared mental model and mutual trust are core components of teamwork training programs like TeamSTEPPS.
Kane-Gill SL, Dasta JF, Buckley MS, et al. Crit Care Med. 2017;45:e877-e915.
… decrease medication errors, adverse drug events remain a significant source of harm. Patients in the intensive care … detection of medication errors and adverse drug events. A previous WebM&M commentary discussed a case involving a serious medication error in the ICU …
Medication reconciliation efforts depend on obtaining an accurate medication history at the time of the clinical encounter. In this study, use of a structured tool by student nurses improved the accuracy of the medication history at hospital admission and was associated with fewer inadvertent medication omissions.
This simulation study identified several mechanisms by which medication errors could occur even when a bar-code medication administration system was used. These included patient identification errors and failure to heed computerized warnings.
Marquard J, Henneman PL, He Z, et al. J Exp Psychol Appl. 2011;17:247-56.
Medication administration errors are a common problem and have been linked to interruptions during nursing workflow. This study used behavioral psychology techniques to analyze how nurses' bedside behaviors influenced their ability to prevent medication administration errors.
This qualitative study explored the cues that nurses use to determine when a patient's clinical condition is worsening, with specific attention to factors influencing nurses' decisions to obtain assistance from the rapid response team or call a "code blue." Rather than relying on specific vital sign abnormalities, nurses relied on a combination of clinical findings (such as altered mental status), help from other experienced nurses, and their prior knowledge of the patient's baseline condition to determine when urgent physician assessment was needed. The study reveals the importance of a positive safety culture in ensuring that frontline staff feel empowered to enlist additional help when necessary.
… the scope of the term patient safety technology and uses a case study to illustrate that sometimes simple … solutions can greatly improve patient safety. … Henneman EA. Patient safety and technology. AACN Adv Crit …
A young woman with Takayasu's arteritis, a vascular condition that can cause BP differences in each arm, was mistakenly placed on a powerful intravenous vasopressor because of a spurious low BP reading. The medication could have led to serious complications.