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.
Ward CE, Taylor M, Keeney C, et al. Prehosp Emerg Care. 2023;27:263-268.
Weight-based calculation errors and lack of weight documentation can lead to medication errors in pediatric patients. This analysis of Maryland emergency medical services (EMS) data including children who received a weight-based medication found that weight documentation was associated with a small but significantly lower rate of medication dose errors, particularly among infants and for epinephrine and fentanyl doses.
Tan J, Ross JM, Wright D, et al. Jt Comm J Qual Patient Saf. 2023;49:265-273.
Wrong-site surgery is considered a never event and can lead to serious patient harm. This analysis of closed medical malpractice claims on wrong-site surgery between 2013 and 2020 concluded that the risk of wrong-site surgery increases with spinal surgeries (e.g., spinal fusion, excision of intervertebral discs). The primary contributing factors to wrong-site surgery was failure to follow policy or protocols (such as failure to follow the Universal Protocol) and failure to review medical records.
Gross TK, Lane NE, Timm NL, et al. Pediatrics. 2023;151:e2022060971-e2022060972.
Emergency room crowding is a persistent factor that degrades safety for patients of all ages. This collection provides background, best practices, and recommendations to reduce emergency department crowding and its negative impact on pediatric care. The publications examine factors that influence crowding and improvement at the input, departmental, and hospital/outpatient stages of emergency care.
Holland R, Bond CM, Alldred DP, et al. BMJ. 2023;380:e071883.
Careful medication management in long-term care residents is associated with improved hospital readmission rates and reduced fall rates. In the UK, pharmacist independent prescribers (PIP) can initiate, change, or monitor medications, and this cluster randomized controlled trial evaluated the effect of PIPs on fall rates. After six months of PIP involvement, fall rates (the primary outcome) were not statistically different than the usual care group, although drug burden was reduced.
Joseph MM, Mahajan P, Snow SK, et al. Pediatrics. 2022;150:e2022059673.
Children with emergent care needs are often cared for in complex situations that can diminish safety. This joint policy statement updates preceding recommendations to enhance the safety of care to children presenting at the emergency department. It expands on the application of topics within a high-reliability framework focusing on leadership, managerial factors, and organizational factors that support safety culture and workforce empowerment to support safe emergency care for children.
Kraemer KL, Althouse AD, Salay M, et al. JAMA Health Forum. 2022;3:e222263.
Nudges (e.g., default order sets) in the electronic health record (EHR) have been shown to encourage safer prescribing of opioids in emergency departments. This study evaluated the effect of nudges to reduce opioid prescribing for opioid-naïve patients with acute pain. Primary care practices were cluster randomized to control, opioid justification in the EHR, peer comparison, or combined opioid justification and peer comparison groups. The three intervention groups showed reduced opioid prescribing compared to control.
Wright DJ, Gabbay J, Le May A. BMJ Qual Saf. 2022;31:450-461.
Healthcare staff use a variety of skills to implement quality improvement and patient safety initiatives. Using case studies and qualitative interviews, this study outlines six “socio-organisational functional and facilitative tasks” (SOFFTs) necessary to successful implementation of quality improvement initiatives. Findings highlight the importance of technical skills as well as relational skills, training and education, and the ability to consider local context.
Hospitals employ a variety of strategies to prevent inpatient falls. Based on data from incident reports, this study used process mapping to identify opportunities to improve timely diagnosis of serious injury resulting from inpatient falls. Researchers found that multiple interventions (e.g., education, changes in the transport process) with small individual effects resulted in a substantial cumulative positive impact on delays in the diagnosis of serious harm resulting from a fall.
Reese T, Wright A, Liu S, et al. Am J Health Syst Pharm. 2022;79:1086-1095.
Computerized decision support alerts for drug-drug interactions are commonly overridden by clinicians. This study examined fifteen well-known drug-drug interactions and identified risk factors that could reduce risk in the majority of interactions (e.g., medication order timing, medication dose, and patient factors).
Gionfriddo MR, Duboski V, Middernacht A, et al. PLoS ONE. 2021;16:e0260882.
Medication reconciliation is a widely used strategy to reduce medication adverse events in acute care; however, its use in primary care is less studied. The aims of this study were to identify behaviors indicative of obtaining a best possible medication history, barriers to medication reconciliation, and what improvements could be made. Numerous inconsistencies related to medication reconciliation were identified (i.e. standardization, knowledge, importance, and inadequate integration).
Schiff GD, Volodarskaya M, Ruan E, et al. JAMA Netw Open. 2022;5:e2144531.
Improving diagnosis is a patient safety priority. Using data from patient safety incident reports, malpractice claims, morbidity and mortality reports, and focus group responses, this study sought to identify “diagnostic pitfalls,” defined as clinical situations vulnerable to errors which may lead to diagnostic errors. The authors identified 21 generic diagnostic pitfall categories involving six different aspects of the clinical interaction – diagnosis and assessment, history and physical, testing, communication, follow-up, and other pitfalls (e.g., problems with inappropriate referral, urgency of the clinical situation not appreciated). The authors suggest that these findings can inform education and quality improvement efforts to anticipate and prevent future errors.
Kotwal S, Fanai M, Fu W, et al. Diagnosis (Berl). 2021;8:489-496.
Previous studies have used virtual patient cases to help trainees and practicing physicians improve diagnostic accuracy. Using virtual patients, this study found that brief lectures combined with 9 hours of supervised deliberate practice improved the ability of medical interns to correctly diagnose dizziness.
Khawagi WY, Steinke DT, Carr MJ, et al. BMJ Qual Saf. 2022;31:364-378.
Patient safety indicators (PSIs) can be used to identify potential patient safety hazards. Researchers used the Clinical Practice Research Datalink GOLD database to examine prevalence, variation, and patient- and practice-level risk factors for 22 mental health-related PSIs for medication prescribing and monitoring in primary care. The authors found that potentially inappropriate prescribing and inadequate medication monitoring commonly affected patients with mental illness in primary care.
One element of conservative prescribing is minimizing the number of medications prescribed. This study compared the number of unique, newly prescribed medications (personal formularies) of primary care physicians across four health systems. Results indicated wide variability in the number of unique medications at the physician and institution levels. Further exploration of personal formularies and core drugs may illuminate opportunities for safer and more appropriate prescribing.
Wright MI, Polivka B, Abusalem S. AORN J. 2021;113:465-475.
Prior research identified variability in perioperative safety culture by provider type and experience. This study found that perioperative nurse engagement (e.g., energy, dedication, resilience) and perioperative nurse certification were significantly associated with self-reported safety culture in the operating room, but length of perioperative nurse experience was not.
Scantlebury A, Sheard L, Fedell C, et al. Digit Health. 2021;7:205520762110100.
Electronic health record (EHR) downtime can disrupt patient care and increase risk for medical errors. Semi-structured interviews with healthcare staff and leadership at one large hospital in England illustrate the negative consequences of a three-week downtime of an electronic pathology system on patient experience and safety. The authors propose recommendations for hospitals to consider when preparing for potential technology downtimes.
Petersen C, Smith J, Freimuth RR, et al. J Amer Med Inform Assoc. 2020;28:677-684.
… J Amer Med Inform Assoc … Clinical decision support (CDS) … of adaptive CDS are outlined. … Petersen C, Smith J, Freimuth RR, et al. Recommendations for the safe, … CDS in the US healthcare system: an AMIA position paper. J Amer Med Inform Assoc. 2021;28(4):677-684. …
D’Amore JD, McCrary LK, Denson J, et al. J Am Med Inform Assoc. 2021;28:1534-1542.
… J Am Med Inform Assoc … Quality measurement is increasingly … quality measurement. … D'Amore JD, McCrary LK, Denson J, et al. Clinical data sharing improves quality measurement and patient safety. J Am Med Inform Assoc. Epub 2021 Mar 14. …