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.
Plint AC, Newton AS, Stang A, et al. BMJ Qual Saf. 2022;31:806-817.
While adverse events (AE) in pediatric emergency departments are rare, the majority are considered preventable. This study reports on the proportion of pediatric patients experiencing an AE within 21 days of an emergency department visit, whether the AE may have been preventable, and the type of AE (e.g., management, diagnostic). Results show 3% of children experienced at least one AE, most of which were preventable.
Hoang R, Sampsel K, Willmore A, et al. CJEM. 2021;23:767-771.
… CJEM … The emergency department (ED) is a complex and high-risk environment. In this study, patient deaths occurring within 7 days of ED … and system factors . … Hoang R, Sampsel K, Willmore A, et al. Remember that patient you saw last week: …
Calder LA, Perry J, Yan JW, et al. Ann Emerg Med. 2021;77:561-574.
Prior research has found that some patients may be at risk for adverse events after discharge from the emergency department (ED). This cohort study analyzed adverse events occurring among patients discharged from the ED with cardiovascular conditions and identified several opportunities for improving safe care, such as adherence to evidence-based clinical guidelines and strengthening dual diagnosis detection.
Plint AC, Stang A, Newton AS, et al. BMJ Qual Saf. 2021;30:216-227.
This article describes emergency department (ED)-related adverse events in pediatric patients presenting to the ED at a pediatric hospital in Canada over a one-year period. Among 1,319 patients at 3-months follow-up, 33 patients (2.5%) reported an adverse event related to their ED care. The majority of these events (88%) were preventable. Most of the events involved diagnostic (45.5%) or management issues (51.5%) and resulted in symptoms lasting more than one day (72.7%).
Lefebvre G, Calder LA, De Gorter R, et al. J Obstet Gynaecol Can. 2019;41:653-659.
Obstetrics is a high-risk practice that concurrently manages the safety of mothers and newborns. This commentary describes the importance of standardization, checklist use, auditing and feedback, peer coaching, and interdisciplinary communication as strategies to reduce risks. The discussion spotlights the need for national guidelines and definitions to reduce variation in auditing and training activities and calls for heightened engagement of health care professionals to improve the safety and quality of obstetric care in Canada. An Annual Perspective reviewed work on improving maternal safety.
Sinclair JE, Austin MA, Bourque C, et al. Prehosp Emerg Care. 2018;22:762-772.
… Prehospital emergency care : official journal of the National Association of EMS Physicians and the National … consequences as the major barrier for paramedics in voluntarily reporting a patient safety event in the prehospital setting . The …
McCleery A, Devenny K, Ogilby C, et al. J Healthc Risk Manag. 2019;38:11-18.
… causes of medical care failure. This commentary describes a framework that applies elements of system safety , … identification of process weakness to inform safety improvement work. An Annual Perspective discussed the need to …
Pevnick JM, Nguyen C, Jackevicius CA, et al. BMJ Qual Saf. 2018;27:512-520.
Among hospitalized patients, adverse drug events (ADEs) are a common and serious source of patient harm. Medication reconciliation at the time of hospital admission reduces preventable ADEs and is a National Patient Safety Goal. In this three-arm, nonblinded, randomized controlled trial, researchers compared pharmacist or pharmacy technician–performed medication reconciliation before admission orders were placed to usual care among patients with at least 10 medications. Pharmacist and technician reconciliation led to similarly large decreases in minor and life-threatening medication order errors. Although pharmacist-led reconciliation reduces in-hospital ADEs in research settings, real-world implementation has been more challenging. Previous WebM&M commentaries highlight the dangers of inadequate medication reconciliation in inpatient and outpatient settings.
Kwok ESH, Calder LA, Barlow-Krelina E, et al. BMJ Qual Saf. 2017;26:439-448.
… BMJ quality & safety … BMJ Qual Saf … Morbidity and mortality conferences are a longstanding patient safety activity. This pre–post study assessed the impact of implementing a structured method to enhance morbidity and mortality …
Calder LA, Pozgay A, Riff S, et al. BMJ Qual Saf. 2015;24:142-148.
… caused by an adverse event. An adverse event was present in 12% of return visits that occurred within 72 hours of the … The authors suggest that this utilization pattern may be a promising trigger tool to identify adverse events. …
Phansalkar S, van der Sijs H, Tucker AD, et al. J Am Med Inform Assoc. 2013;20:489-93.
Clinical decision support system medication alerts have the potential to decrease adverse drug events, but physicians ignore many of these repeated warnings. Alert fatigue is particularly common in drug–drug interaction (DDI) alerts, with prior studies reporting override rates of up to 90%. In this study, an expert panel created a list of 33 class-based, low-priority DDIs that do not warrant interruptive alerts. The goal was to devise a standardized list to help reduce alert fatigue across electronic health records. The authors recommend developing a consortium to maintain this list over time. Dr. David Blumenthal discusses DDI alert fatigue and other issues related to medical information technology in an AHRQ WebM&M interview.
Phansalkar S, Desai AA, Bell D, et al. J Am Med Inform Assoc. 2012;19:735-43.
… Assoc … The impact of clinical decision support systems on improving medication safety has been limited by a lack of standardized and tailored alerts to warn … drug–drug interactions, arrived at through an expert panel approach that included input from pharmacists, …
Nuckols TK, Bell D, Paddock SM, et al. Jt Comm J Qual Patient Saf. 2009;35:139-45.
… Joint Commission journal onquality and patient safety … Jt Comm J Qual Patient Saf … … to understand, analyze, and potentially prevent errors in the hospital setting, though their utility has been … that encourage staff to highlight factors amenable to improvement interventions . …
Nuckols TK, Bell D, Liu H, et al. Qual Saf Health Care. 2007;16:164-8.
… Quality & safety in health care … Qual Saf Health Care … Despite mandates for … filed by nurses, with less than 2% filed by physicians (a problem noted in prior research ). This pattern likely influenced the spectrum of problems reported; only a small proportion of reported incidents related to …
Stille CJ, Jerant A, Bell D, et al. Ann Intern Med. 2005;142:700-708.
… … Ann Intern Med … This review examines the literature on coordination of care and its effectiveness to better understand how a generalist operates in an increasingly complex health care delivery system. The …