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.
Overcrowding in the emergency department (ED) and boarding can place patients at increased risk for adverse events. This article outlines how ED overcrowding occurs and provides several approaches to mitigate risks and enhance patient safety in overcrowded EDs, such as checklists, huddles, and resource allocation.
Hibbert PD, Stewart S, Wiles LK, et al. Int J Qual Health Care. 2023;Epub Oct 17.
Quality improvement and patient safety initiatives require incredible human and financial resources, they so must be selected carefully to achieve the greatest return on investment. This article describes important considerations for hospital leaders when selecting and implementing initiatives. Safety culture, policies and procedures, supporting staff, and patient engagement were notable themes. The included "patient safety governance model" provides a framework to develop patient safety policy.
Samost-Williams A, Rosen R, Cummins E, et al. Jt Comm J Qual Patient Saf. 2023;Epub Oct 15.
Team-based morbidity and mortality conferences (TBMMs) involve multidisciplinary or interdisciplinary teams in discussions about complex cases and medical errors. This survey of 1,466 perioperative health care professionals found positive perceptions of TBMMs and traditional Morbidity and Mortality Conferences, but identified several barriers to effective implementation of TBMMs, including unsupportive leadership and fear of professional consequences.
Winter SG, Sedgwick C, Wallace-Lacey A, et al. Clin Ther. 2023;45:928-934.
The VIONE (Vital, Important, Optional, Not indicated, and Every medication has an indication) tool is used to reduce polypharmacy and potentially inappropriate prescribing. This article provides an overview of VIONE implementation and dashboards used to track VIONE implementation and its impact on prescribing across over 130 Veterans Health Administration medical centers. Since implementation in 2016, VIONE has led to the discontinuation of over 1.6 million medication orders by more than 15,000 providers.
O’Leary KJ, Johnson JK, Williams MV, et al. Ann Intern Med. 2023;Epub Oct 31.
Teamwork is an essential component of ensuring high quality, safe healthcare. This article describes findings from the Redesigning SystEms to Improve Teamwork and Quality for Hospitalized Patients (RESET) study, which evaluated the impact of complementary interventions to redesign unit-based care (unit-based physician teams, nurse-physician co-leadership, interprofessional rounds, performance reports, patient engagement) on interprofessional teamwork and patient outcomes. Findings demonstrate improved teamwork climate scores among nurses (but not physicians), but researchers did not identify a significant impact on patient outcomes.
Terwilliger IA, Johnson JK, Manojlovich M, et al. Jt Comm J Qual Patient Saf. 2023;Epub Sep 4.
Quality improvement and patient safety initiatives are difficult to implement and sustain. This commentary describes factors that contributed to successful implementation of the REdesigning SystEms to Improve Teamwork and Quality for Hospitalized Patients (RESET) study. Consistent with other research, important factors included leadership involvement, goal alignment, site leader commitment, and nurse/physician agreement that improvement was needed. The authors suggest hospital leaders consider these contextual factors prior to implementing similar improvement projects.
Alqenae FA, Steinke DT, Belither H, et al. Drug Saf. 2023;46:1021-1037.
Miscommunication between hospitals and community pharmacists at patient discharge can result in incorrect or incomplete medication distribution to patients. This study describes utilization and impact of the Transfers of Care Around Medicines (TCAM) service post-hospital discharge at community pharmacies. An increasing percentage of TCAM referrals were completed post-intervention, but 45% were not completed at all or took longer than one month. The impact of the TCAM service on adverse drug events (ADE) and unintentional medication discrepancies (UMD) was uncertain. Future research may explore reasons for low/late completions or focus on high-risk medications, as those were associated with the most ADE and UMD.
Lea W, Lawton R, Vincent CA, et al. J Patient Saf. 2023;19:553-563.
Organizational incident reporting allows for investigation of contributing factors and formation of improvement recommendations, but some recommendations are weak (e.g., staff training) and do not result in system change. This review found 4,579 recommendations from 11 studies, with less than 7% classified as "strong". There was little explanation for how the recommendations were generated or if they resulted in improvements in safety or quality of care. The authors contend additional research into how recommendations are generated and if they result in sustained improvement is needed.
Moyal-Smith R, Etheridge JC, Turley N, et al. BMJ Qual Saf. 2023;Epub Sep 21.
Implementation challenges can hinder the effectiveness of the WHO Surgical Safety Checklist (SSC). This study describes the validation of the Checklist Performance Observation for Improvement (CheckPOINT) tool to assess SSC implementation fidelity. Based on testing in simulated and real-life clinical practice, researchers found that that the tool can reliably assess implementation fidelity and identify opportunities for improvement.
Samost-Williams A, Rosen R, Hannenberg A, et al. Ann Surg Open. 2023;4:e321.
Morbidity and mortality conferences offer important opportunities for healthcare teams to discuss adverse events, learn from errors, and improve patient safety. This systematic review examined beneficial aspects of perioperative team-based morbidity and mortality (TBMM) conferences. The authors found that TBMM conferences generally led to improvements in patient safety, quality improvement, and educational outcomes and that certain factors (case preparation, standardized presentation format, effective facilitation) increase TBMM benefits.
Minors AM, Yusaf TC, Bentley SK, et al. Simul Healthc. 2023;18:226-231.
In situ simulations offer unique opportunities to improve teamwork and identify system vulnerabilities. This study examined risks – “no go” considerations - associated with in situ simulations focused on cardiac arrest in pregnancy and identified factors that could lead simulations to be canceled or postponed to ensure patient or staff safety.
Longo BA, Schmaltz SP, Williams SC, et al. Jt Comm J Qual Patient Saf. 2023;49:511-520.
Supporting and improving clinician well-being has long been a safety focus and received renewed focus during the COVID-19 pandemic. This study sought to understand efforts undertaken to support clinicians’ well-being in Joint Commission-accredited hospitals and Federally Qualified Health Centers (FQHC). Only half of responding hospitals and FQHCs reported implementing at least one action towards improving clinician well-being (e.g., establishing a wellness committee) and few had implemented a comprehensive approach.
McCarthy SE, Hogan C, Jenkins L, et al. BMJ Open Qual. 2023;12:e002270.
Debriefing after significant clinical events helps affected staff develop a shared mental model of what happened, why it happened, and how it can be prevented in the future. This paper describes development of training videos on after action reviews (AAR)s, a type of debriefing. The videos introduce AAR, show a simulated AAR debriefing, offer techniques for handing challenging situations within an AAR, and reflections on the benefits. The videos are available with the online version of the paper.
Christopher D, Leininger WM, Beaty L, et al. Am J Med Qual. 2023;38:165-173.
Staff engagement in safety and quality improvement efforts fosters a culture of safety and can reduce medical errors. This survey of 52 obstetrics and gynecology departments at academic medical centers found that few departments provided faculty with protected time or financial support for quality improvement activities, and only 5% of departments included a patient representative on the quality committee.
Williams SR, Sebok-Syer SS, Caretta-Weyer H, et al. BMC Med Educ. 2023;23:434.
Standardizing handoff training in residency programs can lead to safer, more effective handoffs. Researchers surveyed a sample of 687 residents and fellows from over 30 specialties about handoff training perspectives. Participants reported wide variability in handoff content and identified important aspects of handoff training (critical handoff elements, the impact of systems-level factors, impact of the handoff on providers and patients, professional duty, and addressing blame or guilt related to poor handoff experiences).
Dunbar EG, Massey AC, Lee YL, et al. Am Surg. 2023;89:3272-3274.
Medication reconciliation is an important care process anytime a patient transitions from one care setting to another, including emergency department to hospital admission. This study sought to determine the incidence of completed medication reconciliation for admitted trauma patients and the number of identified discrepancies. Of the 89 patients included in the study, more than a quarter did not receive an admission medication reconciliation (AMR), and of those with an AMR, 48% had at least one unintended discrepancy, indicating the importance of completing medication reconciliation for all admitted trauma patients.
Kieren MQ, Kelly MM, Garcia MA, et al. Acad Pediatr. 2023;Epub Jun 9.
Parents of children with medical complexity are an important part of the care team and can raise awareness of safety concerns. This study included parents of children with medical complexity who had reported safety concerns to members of their child's healthcare team. Parents whose concerns were validated and addressed felt increased trust in the team and hospital, whereas those whose concerns were invalidated or ignored felt disrespected and judged.
Abraham J, Rosen M, Greilich PE eds. Jt Comm J Qual Patient Saf. 2023;49(8):341-434.
Handoffs occur several times during a surgical procedure, increasing the risk of communication mistakes and misunderstandings. This special issue explores perioperative handoffs and strategies to improve them. Topics covered include information accuracy, teamwork science, and artificial intelligence.
Vickers-Smith R, Justice AC, Becker WC, et al. Am J Psych. 2023;180:426-436.
Racial and ethnic biases can affect diagnosis and negatively impact patient safety. Based on a sample of over 700,000 veterans, this study found that Black and Hispanic individuals consumed similar amounts of alcohol to White individuals but were more likely to be diagnosed with alcohol use disorder (AUD).
Accurate dosing and administration of liquid medications to children can be difficult for parents or caregivers. In this study, family caregivers and clinicians described their experiences at hospital discharge relating to both general and liquid-specific medication counseling. Clinicians and caregivers both stated that teach-back protocols were helpful but inconsistently used. Caregivers were not always shown how to draw up liquid into the syringes leading to them feeling uncertain about giving the correct dose. Health literacy and speaking languages other than English were also described as challenges.