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.
Rabbani N, Pageler NM, Hoffman JM, et al. Appl Clin Inform. 2023;14:521-527.
Implementation of or upgrades to new electronic health records (EHR) is a complex process which sometimes results in unforeseen negative consequences. This study examines hospital-acquired conditions (HACs) and care bundle compliance rates at 27 pediatric hospitals before, during, and after implementation or upgrade of EHR systems. Contrary to previous studies, no significant differences were found in either HAC or bundle compliance rates.
Coffey M, Marino M, Lyren A, et al. JAMA Pediatr. 2022;176:924-932.
The Partnership for Patients (P4P) program launched hospital engagement networks (HEN) in 2011 to reduce hospital-acquired harms. This study reports on the outcomes of eight conditions from one HEN, Children's Hospitals' Solutions for Patient Safety (SPS). While the results do show a reduction in harms, the authors state earlier claims of improvement may have been overstated due to failure to not adjust for secular improvements. The co-director of Partnership for Patients, Dr. Paul McGann, was interviewed in 2016 for a PSNet perspective.
Tawfik DS, Thomas EJ, Vogus TJ, et al. BMC Health Serv Res. 2019;19:738.
Prior research has found that perceptions about safety climate varies across neonatal intensive care units (NICUs). This large cross-sectional study examining the impact of caregiver perceptions of safety climate on clinical outcomes found that stronger safety climates were associated with lower risk of healthcare-associated infections, but climate did not affect mortality rates.
Randall KH, Slovensky D, Weech-Maldonado R, et al. Jt Comm J Qual Patient Saf. 2019;45:164-169.
… Jt Comm J Qual Patient Saf … Jt Comm J Qual Patient Saf … High … challenge. Researchers surveyed hospitals in the Children's Hospitals' Solutions for Patient Safety (CHSPS) network to … to health care. … Randall KH, Slovensky D, Weech-Maldonado R, Patrician PA, Sharek PJ. Self-Reported Adherence to High …
Caruso TJ, Munshey F, Aldorfer B, et al. Jt Comm J Qual Patient Saf. 2018;44:552-556.
Surgical time outs are a required practice prior to incision. This project report discusses the design and testing of an additional step before performing the time out in pediatric surgical cases. The authors found the innovation to be widely accepted by perioperative teams, demonstrating its potential to support safe care.
Stockwell DC, Landrigan CP, Toomey SL, et al. Pediatrics. 2018;142:e20173360.
This study used a trigger tool (the Global Assessment of Pediatric Patient Safety) to examine temporal trends in adverse event rates at 16 randomly selected children's hospitals. Adverse event rates did not significantly change at either teaching or nonteaching hospitals from 2007 to 2012. Interestingly, nonteaching hospitals had lower error rates than teaching facilities, although the increased complexity of patients at teaching hospitals may account for this finding. The results of this study mirror those of a similar study conducted in adult hospitals from 2002 to 2007. An accompanying editorial notes that quality improvement collaboratives have achieved reductions in hospital-acquired conditions at children's hospitals and speculates that these discordant findings could be due to the fact that trigger tools are able to detect a broader range of adverse events and thus may provide a more accurate picture of safety. A WebM&M commentary discussed a preventable medication error at a children's hospital.
Stockwell DC, Landrigan CP, Schuster MA, et al. Pediatr Qual Saf. 2018;3:e081.
The Centers for Medicare and Medicaid Services (CMS) has successfully reduced preventable harm from hospital-acquired conditions (HACs) through financial penalties to hospitals. Hospitals nationwide have invested substantial resources in reducing the HACs on the CMS nonpayment list, raising concern about whether institutions may be neglecting other types of preventable harm. Researchers used an all-cause harm trigger tool to assess what proportion of harms that occurred at six children's hospitals were HACs versus harms excluded from the CMS list. Only 58 of 240 harms were considered HACs. Some common harms identified outside the scope of HACs were intravenous catheter infiltration, surgical complications, and pain. Prior WebM&M commentaries have discussed harms from hospital-acquired infections as well as the unintended consequences of public hospital quality reporting.
Researchers surveyed pediatric cardiac intensive care unit providers across three tertiary cardiac centers in the United States. More than 80% of respondents perceived diagnostic errors to be common and 65% reported errors causing permanent harm to patients. Improving feedback and teamwork were frequently suggested as strategies for reducing diagnostic error.
Lyren A, Brilli RJ, Zieker K, et al. Pediatrics. 2017;140.
Improving patient safety often involves multifaceted interventions intended to change complex workflows. This prospective cohort study examined whether a collaborative improvement initiative across 33 pediatric hospitals could augment patient safety. Hospitals volunteered to be part of the collaborative and paid an annual fee to participate. All but one submitted their safety data for inclusion in the study. The intervention involved identification and dissemination of evidence-based practices to reduce hospital-acquired conditions and prevent serious adverse events. Each hospital implemented these best practices locally according to their preferences. The collaborative provided virtual and in-person training for patient safety processes, such as unit-based safety rounds, root cause analysis, and inclusion of patients and families on hospital committees. Rates of hospital-acquired conditions and serious adverse events declined over time during the 3-year study. Because there were no concurrent control hospitals, it is not clear whether these improvements can be attributed to the intervention. The authors conclude that participation in a learning collaborative can enhance patient safety.
Detecting and measuring patient safety hazards remains challenging, but assessing the potential for a given safety problem to cause harm is even more difficult. Experts therefore sought to achieve consensus around an all-cause pediatric harm measurement tool using a modified Delphi process. They vetted 108 possible trigger tools that can indicate an incipient safety risk, including use of reversal agents for high-risk medications and diagnosis of health care–associated infections. After multiple rounds of discussion and evidence review, investigators produced a list of 51 triggers, which they plan to pilot test. The authors assert that this work is the first step toward identifying harm to pediatric patients in real-time.
Profit J, Lee HC, Sharek PJ, et al. BMJ Qual Saf. 2016;25:954-961.
Health care organizations measure safety climate by surveying providers and staff at all levels. Investigators assessed safety culture and teamwork in 44 neonatal intensive care units using two different survey tools—the Safety Attitudes Questionnaire and the Hospital Survey on Patient Safety Culture. They found significant variation in safety and teamwork climate scales of both tools, indicating that the instruments should not be used interchangeably.
Landrigan CP, Stockwell DC, Toomey SL, et al. Pediatrics. 2016;137.
Trigger tools are a widely used method for detecting safety hazards in hospitalized patients. However, there is limited literature on using trigger tools in pediatric patients, as most existing tools were developed in adult patient populations. This study reports on the development and refinement of a novel trigger tool for hospitalized children. In testing at academic and community hospitals, the tool was found to accurately identify adverse events. Although other studies have raised concerns about the interrater reliability of trigger tools, in this study, agreement between reviewers regarding the presence of an adverse event improved with increased experience with the tool. The authors state that the tool can be used for measurement purposes, allowing institutions to track their performance over time and compare rates of safety events across institutions.
Stockwell DC, Bisarya H, Classen D, et al. Pediatrics. 2015;135:1036-42.
Trigger tools are widely used as a means of detecting adverse events, but most of the existing triggers were developed and validated in adult populations. This study reports on the validation of a trigger tool for hospitalized pediatric patients, based on the Institute for Healthcare Improvement's Global Trigger Tool. In a retrospective chart review across six academic children's hospitals, the tool identified harm in 40% of admissions—a proportion comparable to a similar study in adult inpatients. Nearly half of these incidents were considered preventable. Other studies using slightly different pediatric trigger tools have found a lower incidence of adverse events. The use of trigger tools was discussed in a previous AHRQ WebM&M perspective.
Sexton B, Sharek PJ, Thomas EJ, et al. BMJ Qual Saf. 2014;23:814-22.
Leadership WalkRounds, in which senior leadership visits directly with frontline staff on their clinical units with the goal of identifying and addressing safety concerns, has shown potential as a means of improving safety culture. However, initial enthusiasm for this approach has been tempered by a recent qualitative study and a randomized trial—both showed that walkrounds had little effect on safety culture. Conducted in 44 neonatal intensive care units, this cross-sectional study found that units who received feedback from walkrounds had lower rates of burnout and more positive perceptions of safety culture. The results of this investigation may help explain why walkrounds were not associated with improvements in other studies—when walkrounds are performed in a perfunctory fashion or when senior leadership does not systematically follow up on issues identified, frontline workers may become cynical and perceptions of safety culture may actually worsen.