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.
Zimbro KS, Bridges C, Bunn S, et al. J Nurs Care Qual. 2023;Epub Oct 2.
… J Nurs Care Qual … Inpatient falls are a persistent patient safety concern. In this study, … analyzed electronic health record (EHR) data from a 13-hospital health care system to examine whether remote …
Webster CS, Mahajan R, Weller JM. Br J Anaesth. 2023;131:397-406.
Systems involving people, tools, technology, and work environments must interact effectively to ensure the delivery of safe, effective care. This narrative review uses a sociotechnical perspective to explore the inter-relationship between technology and the human work environment during the delivery of anesthesia in the operating room. The authors discuss systems-level approaches, such as such as surgical safety checklists, as well as the role of resilience and new technologies (i.e., artificial intelligence).
Bijok B, Jaulin F, Picard J, et al. Anaesth Crit Care Pain Med. 2023;42:101262.
Human factors influence how humans and systems interact to make processes more reliable or more error-prone during both normal and unexpected circumstances. This guideline provides recommendations centered on elements of communication, the organization, the work environment, and training to guide the consideration of human factors in improvement actions during critical anesthesia or intensive care situations.
Kirwan G, O’Leary A, Walsh C, et al. Eur J Hosp Pharm. 2023;30:86-91.
Patients are particularly vulnerable to medication errors during transitions of care, such as hospital discharge. Based on clinical judgement from four experts assessing 81 cases involving medication errors at discharge, the authors estimated that between 61-85% would result in additional healthcare utilization (e.g., additional prescriptions, primary care or ED visits, hospital or ICU admissions) and additional costs.
Johansen JS, Halvorsen KH, Svendsen K, et al. BMC Health Serv Res. 2022;22:1290.
Reducing unplanned hospital readmissions is a priority patient safety focus, and numerous interventions with hospital pharmacists have been developed. In this study, hospitalized adults aged 70 years and older were randomized to receive standard care or the IMMENSE intervention. The IMprove MEdicatioN Safety in the Elderly (IMMENSE) intervention is based on the integrated medicine management (IMM) model and consists of five steps, including medication reconciliation, patient counseling, and communication with the patient’s primary care provider. There was no significant difference in emergency department visits or readmissions between control and intervention within 12 months of the index hospital visit.
Parker H, Frost J, Day J, et al. PLoS ONE. 2022;17:e0271454.
Prophylactic antimicrobials are frequently prescribed for surgical patients despite the risks of antimicrobial overuse (e.g., resistance). This review summarizes how and why antimicrobials continue to be prescribed in surgical settings despite evidence of overuse. Eight overarching concepts were identified: hierarchy; fear drives action; deprioritized; convention trumps evidence; complex judgments; discontinuity of care; team dynamics; and practice environment.
Fawzy A, Wu TD, Wang K, et al. JAMA Intern Med. 2022;182:730-738.
Black and brown patients have experienced disproportionately poorer outcomes from COVID-19 infection as compared with white patients. This study found that patients who identified as Asian, Black, or Hispanic may not have received timely diagnosis or treatment due to inaccurately measured pulse oximetry (SpO2). These inaccuracies and discrepancies should be considered in COVID outcome research as well as other respiratory illnesses that rely on SpO2 measurement for treatment.
Cedillo G, George MC, Deshpande R, et al. Addict Sci Clin Pract. 2022;17:28.
In 2016, the Centers for Disease Control (CDC) issued an opioid prescribing guideline intended to reverse the increasing death rate from opioid overdoses. This study describes the development, implementation, and effect of a safe prescribing strategy (TOWER) in an HIV-focused primary care setting. Providers using TOWER were more adherent to the CDC guidelines, with no worsening patient-reported outcome measures.
Long JA, Webster CS, Holliday T, et al. Simul Healthc. 2022;17:e38-e44.
Simulation training is a valuable tool to improve patient care. In this study, researchers explored latent safety threats identified during multidisciplinary simulation-based team training delivered to 21 hospitals in New Zealand. Common latent threats were related to knowledge and skills, team factors, task- or technology-related factors, and work environment threats.
Moore MR, Mitchell SJ, Weller JM, et al. Anaesthesia. 2021;77:185-195.
Surgical safety checklists (SSCs) have been shown to improve patient outcomes and reduce complications. In this study, postoperative mortality and increased days alive and out of hospital were measures for surgical patients in the 18-month period prior to implementation of the SSC and the 18-month period following implementation. Changes in mortality and days alive and out of hospital during these time periods were indistinguishable from longer-term trends. Researchers noted Māori patients had worse outcomes than non-Māori patients.
Mazor KM, Kamineni A, Roblin DW, et al. J Patient Saf. 2021;17:e1278-e1284.
Patient engagement and encouraging speaking up can promote safety. This randomized study found that patients undergoing cancer treatment who were randomized to an active outreach program were significantly more likely to speak up and report healthcare concerns than patients in the control group.
Robinson-Lane SG, Sutton NR, Chubb H, et al. J Am Med Dir Assoc. 2021;22:2245-2250.
… J Am Med Dir Assoc … The COVID-19 pandemic has exacerbated … be more vulnerable to COVID-19-related complications (e.g., higher 60-day readmission rates) and extended recovery … periods (e.g., longest delays in returning to work). … Robinson-Lane SG, Sutton NR, Chubb H, et al. Race, ethnicity, …
LaGrone LN, McIntyre LK, Riggle A, et al. J Trauma Acute Care Surg. 2020;89:1046-1053.
… J Trauma Acute Care Surg … The authors examined contributors … occurring between 1996-2004 and 2005-2014 and identified a shift from deaths occurring during the early phase of care (e.g., failed resuscitation and hemorrhage) to deaths occurring …
Panda N, Etheridge JC, Singh T, et al. World J Surg. 2021;45:1293-1296.
The World Health Organization (WHO) surgical safety checklist is widely used in surgical settings to prevent errors. This multinational panel representing multiple clinical specialties identified 16 recommendations for checklist content modification and implementation during the COVID-19 pandemic. These recommendations exemplify how the checklist can be adapted to meet urgent and emerging needs of surgical units by targeting important processes and encouraging critical discussions.
Auerbach AD, Bates DW, Rao JK, et al, eds. Ann Intern Med. 2020;172(11_Supp):S69-S144.
Research and error reporting are important strategies to uncover problems in health system performance. This special issue highlights vendor transparency and context as important areas of focus to ensure electronic health records (EHR) research and reporting help improve system reliability. The articles cover topics such as a framework for research reporting, design of randomized controlled trials for technology studies, and designing research on patient portal enhancement.
Oliva EM, Bowe T, Manhapra A, et al. BMJ. 2020;386:m283.
Guidelines recommend safe opioid prescribing but also warn against sudden tapering or discontinuation of opioids, which can lead to harm among patients physically dependent on the medications. Using data from the Veterans Heath Administration (VA), this observational study examined the association between opioid treatment cessation and death from overdose or suicide. Researchers found an increased risk of death from overdose or suicide regardless of the length of treatment; the risk of death increased with longer treatment duration. The authors recommend that efforts to improve opioid safety include assessing risks that may place patients at risk for overdose or suicide whether they continue or stop opioid treatment.
Ward M, Shé ÉN, De Brún A, et al. BMC Med Edu. 2019;19:232.
“Serious games” are becoming more prevalent in health care. This article describes a "serious game" PlayDecide for use of multidisciplinary healthcare teams in which the teams are presented with real-world case stories of events and incidents, incorporating the perspectives of healthcare professionals and patients. Players are tasked with exchanging and discussing perspectives and information, then working towards a shared group policy position around error reporting and patient safety. This study evaluated the use of the PlayDecide framework in two large urban academic medical centers and noted a significant change in error reporting behavior among junior faculty post-intervention.