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.
Dykes PC, Curtin-Bowen M, Lipsitz S, et al. JAMA Health Forum. 2023;4:e225125.
Patient falls are associated with poorer clinical outcomes, and increased costs to the health system. This study describes the economic costs of implementing the Fall Tailoring Interventions for Patient Safety (Fall TIPS) Program in eight American hospitals. Results show the Fall TIPS program reduced falls by 19%, avoiding over $14,000 of costs per 1,000 patient days.
Samal L, Khasnabish S, Foskett C, et al. J Patient Saf. 2022;18:611-616.
Adverse events can be identified through multiple methods, including trigger tools and voluntary reporting systems. In this comparison study, the Global Trigger Tool identified 79 AE in 88 oncology patients, compared to 21 in the voluntary reporting system; only two AE were identified by both. Results indicate multiple sources should be used to detect AE.
Patient safety dashboards are used to communicate real-time patient data to appropriately augment care. This study found that higher usage of an electronic patient safety dashboard resulted in lower 30-day readmission rates among patients discharged from adult medicine units compared to lower usage groups.
Okpalauwaekwe U, Tzeng H-M. Patient Relat Outcome Meas. 2021;12:323-337.
Patients transferred from hospitals to skilled nursing facilities (SNFs) are vulnerable to adverse events. This scoping review identified common extrinsic factors contributing to adverse events among older adults during rehabilitation stays at skilled nursing facilities, including inappropriate medication usage, polypharmacy, environmental hazards, poor communication between staff, lack of resident safety plans, and poor quality of care due to racial bias, organizational issues, and administrative issues.
Tzeng H-M, Raji MA, Chou L-N, et al. J Nurs Care Qual. 2021;37:6-13.
Potentially inappropriate medications (PIMs) for older adults carry a high risk of adverse drug events. Using a sample of Medicare beneficiaries from 2015 to 2018, researchers assessed the impact of state scope of practice regulations for nurse practitioners (NPs) on PIM prescribing patterns compared to primary care physicians. Findings indicate that the PIM prescribing rate is lower in states with full NP practice and lower among NPs than among physicians.
Tzeng H-M, Jansen LS, Okpalauwaekwe U, et al. J Nurs Care Qual. 2021;36:327-332.
Patient falls are an ongoing patient safety concern, yet mitigating falls among inpatients remains challenging. This article describes one nursing home’s experience adapting the Fall TIPS program for use in their patient population. The program, which emphasizes tailored fall-prevention and patient-family engagement, resulted in a decrease in the rate of falls and injuries.
Dykes PC, Lowenthal G, Faris A, et al. J Patient Saf. 2021;17:56-62.
Failure to rescue – the lack of adequate response to patient deterioration – has been associated with adverse patient outcomes, particularly in acute care settings. This article describes two health systems’ efforts to implement in-hospital Clinical Monitoring System Technology (CMST) which positively impacted failure-to-rescue events. The authors identified barriers and facilitators to CMST use, which informed the development of an implementation toolkit addressing readiness, implementation, patient/family introduction, champions, and troubleshooting.
Bhasin S, Gill TM, Reuben DB, et al. N Engl J Med. 2020;383:129-140.
This study randomized primary care practices across ten health care systems to evaluate the effectiveness of a multifactorial intervention to prevent falls with injury, which included risk assessment and individualized plans administered by specially trained nurses. The intervention did not result in a significantly lower rate of serious fall injury compared to usual care.
Christiansen TL, Lipsitz S, Scanlan M, et al. Jt Comm J Qual Patient Saf. 2020.
The Fall TIPS (Tailoring Interventions for Patient Safety) program has been shown to be effective in preventing inpatient falls through formal risk assessment and tailored patient care plans. This study demonstrated that patients with access to the Fall TIPS program are more engaged and feel more confident in their ability to prevent falls than those who were not exposed to the program.
Blandford A, Dykes PC, Franklin BD, et al. Drug Saf. 2019;42:1157-1165.
Intravenous medication infusions are an important target for safety interventions. Many infused medications, such as opioids and chemotherapy, require vigilant adherence to protocol to prevent harm. Technical solutions to infusion errors such as computerized provider order entry, barcode medication administration, and smart infusion pumps have been implemented with some success. Investigators compared infusion errors in the United States, where all three technical interventions are common, to the United Kingdom, where those technical interventions are rare. Minor errors were common in each country, but only 0.8% of infusions placed patients at serious risk of harm. Although the details of errors in both countries differed in detail, rates of error and harm were similar. A WebM&M commentary described a chemotherapy infusion error that caused renal failure.
Mueller SK, Shannon E, Dalal A, et al. J Patient Saf. 2021;17:e752-e757.
This single-site survey of resident and attending physicians across multiple specialties uncovered multiple safety vulnerabilities in the process of interhospital transfer. Investigators found that physicians and patients were both dissatisfied with timing of transfers and that critical patient records were missing upon transfer. These issues raise safety concerns for highly variable interhospital transfer practices.
Schiff G, Klinger E, Salazar A, et al. J Gen Intern Med. 2019;34:285-292.
In this cluster-randomized trial, researchers examined the impact of an automated phone call with the option of transfer to a live pharmacist on detecting potential adverse drug events for patients newly started on medications for certain conditions in the primary care setting. Patients receiving the intervention were more likely to have medications stopped with documentation reflecting adverse effects.
Schnock KO, Dykes PC, Albert J, et al. Drug Saf. 2018;41:591-602.
Intravenous medication administration errors related to smart pumps can compromise patient safety. Prior research has shown that such errors are common and often involve incorrect dosing and workarounds. Researchers describe the development and implementation of a multicomponent safety intervention bundle developed to reduce medication administration errors associated with smart pump use. Although both the overall error rate and medication error rate per 100 medication administrations decreased, the intervention did not lead to a reduction in the rate of potentially harmful errors. A past PSNet perspective discussed the use of smart pumps to improve safety.
Lyons I, Furniss D, Blandford A, et al. BMJ Qual Saf. 2018;27:892-901.
Errors and discrepancies in intravenous infusions were common in this study performed at two English hospitals, but only a small proportion of errors led to patient harm. The use of smart pumps did not appear to protect against errors.
Nanji KC, Seger DL, Slight SP, et al. J Am Med Inform Assoc. 2018;25:476-481.
Medication-related clinical decision support is a ubiquitous component of computerized provider order entry (CPOE). Alerts are intended to reduce medication errors and may improve adherence to recommended treatments, but they have yet to improve clinical outcomes. This cross-sectional study examined how often inpatient providers overrode clinical alerts as well as whether those overrides were appropriate. Over 3 years, clinicians overrode nearly 340,000 alerts. While nearly all duplicate drug alert and drug allergy overrides were appropriate, most renal or age contraindication overrides were inappropriate. Although this single institution investigation of a homegrown, older CPOE system may not be generalizable to more common electronic health records, it does illustrate how alert fatigue compromises patient safety. A previous WebM&M commentary discussed the challenges of designing safe CPOE.
Mlaver E, Schnipper JL, Boxer RB, et al. Jt Comm J Qual Patient Saf. 2017;43:676-685.
This commentary describes an AHRQ-funded project to develop an interactive web-based dashboard to communicate patient data in real time to augment safety of care activities. The authors review important functions of the tool, considerations for future development, and initial evaluation results.