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.
Fagan K, Sabel A, Mehler PS, et al. Am J Med Qual. 2012;27:480-6.
This study revealed a high incidence of false-positive vital sign abnormalities that meet established thresholds for triggering rapid response activation. These findings are important when considering potential automated triggering systems.
Stahel PF, Sabel A, Victoroff MS, et al. Arch Surg. 2010;145:978-84.
Efforts to prevent wrong-site and wrong-patient surgical errors (WSPEs) initially focused on procedural disciplines and operating room procedures. However, this analysis of WSPEs that were voluntarily reported to a Colorado malpractice insurance company database found that a significant proportion of WSPEs were committed by physicians in non-surgical fields (such as internal medicine). Root cause analysis revealed a number of contributing causes, with diagnostic errors and communication errors the primary culprits. Interestingly, the injured patients did not file a malpractice lawsuit in the vast majority of cases. This study confirms and extends prior research showing that many WSPEs actually occur outside the operating room. The authors call for strict adherence to the Joint Commission Universal Protocol in order to prevent these never events.
Stahel PF, Flierl MA, Smith WR, et al. Am J Med Qual. 2010;25:398-401.
An orthopedic surgery department implemented a confidential, real-time system for reporting intraoperative adverse events and analyzed these events in structured morbidity and mortality conferences. Although physicians felt this process improved patient care, it resulted in a significant increase in reported error rates, which, as the authors point out, could have resulted in lower quality ratings for the department.
Moldenhauer K, Sabel A, Chu ES, et al. Jt Comm J Qual Patient Saf. 2009;35:164-74.
A national campaign to save lives in the hospital setting initially catalyzed implementation of rapid response systems. Although past research led to controversy over their widespread adoption, the ability to identify at-risk patients and prevent them from clinically deteriorating remains important. This study developed a clinical triggers program that focused on systematic use of existing housestaff teams to respond to patients in distress. Rather than a dedicated and resource-intensive rapid response team, this hospital required nurses to trigger a call to the primary team based on specific physiologic parameters, and then required responding housestaff to complete a form following direct communication with the bedside nurse. The guidelines also required timely discussion with an attending physician, which ultimately led to a decrease in non-ICU cardiopulmonary arrests and ICU bounceback rates. While their model may apply only to similar teaching institutions, it does provide a unique prototype for addressing failure to rescue initiatives that leverage existing resources rather than creating new ones.