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.
Grubenhoff JA, Bakel LA, Dominguez F, et al. Jt Comm J Qual Patient Saf. 2023;49:547-557.
Clinical care pathways (CP) standardize care to ensure evidence-based practices are consistently followed. This study analyzed missed diagnostic opportunities (MDO) of pediatric musculoskeletal infections that could have been mitigated had the CP recommendations been adhered to. Misinterpretation of laboratory results was a critical contributor to MDO by both pediatric emergency providers and orthopedic consultants.
Kamta J, Fregoso B, Lee A, et al. Prehosp Emerg Care. 2023;Epub Jul 28.
Handoffs from emergency medical services (EMS) to the emergency department (ED) are vulnerable to communication errors due to the time-pressured environment. This study reports on the implementation of an electronic health record (EHR) tool that added pre-hospital medication administration to the ED triage note to reduce medication administration errors (MAE). Although most ED providers reported they "always" review the triage note, MAE rates did not improve following implementation.
Aiken LH, Lasater KB, Sloane DM, et al. JAMA Health Forum. 2023;4:e231809.
While the association between clinician burnout and patient safety are not new, the COVID-19 pandemic brought this safety concern back to the forefront. In this study conducted at 60 US Magnet hospitals, nurses and physicians reported high levels of burnout and rated their hospital unfavorably on patient safety. Increased nurse staffing was the top recommendation to reduce burnout with less emphasis on wellness and resilience programs.
Ames SG, Delaney RK, Houtrow AJ, et al. Pediatrics. 2023;152:e2022060975.
People with disabilities encounter a variety of system- and clinician-level barriers when seeking healthcare. This study reports on disability-based discrimination faced by children with medical complexities and their caregivers. Apathy, clinician assumptions, and lack of clinician knowledge were identified as drivers of discrimination resulting in limited accessibility, substandard care, and dehumanization.
Dadich A, Rodrigues J, De Bellis A, et al. Dementia (London). 2023;22:1057-1076.
Safety II involves studying what goes right in patient care instead of what went wrong. Using a video reflexive ethnography method and a Safety II approach, researchers analyzed the ways in which staff provided safe care in a specialized dementia ward. Identified themes included negotiating risk and balancing personhood vs. protocols.
Context (e.g., patient characteristics, setting) can influence clinical reasoning and increase the risk for diagnostic errors. This article explores the ways in which individual-, team-, and system-level contextual factors impact reasoning, clinician performance and risk of error. The authors propose a multilevel framework to better understand how contextual factors impact clinical reasoning.
Schneider P, Lorenz A, Menegay MC, et al. Am J Obstet Gynecol MFM. 2023;5:100912.
Reducing maternal morbidity and mortality continues to be a patient safety priority in the United States. The article describes the implementation of a quality improvement initiative in Ohio to improve outcomes for patients with a severe hypertensive event during pregnancy or postpartum. Among 29 participating hospitals between July 2020 and September 2021, the researchers identified sustained improvements in timely and appropriate treatment for severe hypertension, timely follow-up appointment after hospital discharge, and patient education about urgent maternal warning signs across both non-Hispanic Black and White pregnant or postpartum people.
Jeffries M, Salema N-E, Laing L, et al. BMJ Open. 2023;13:e068798.
Clinical decision support (CDS) systems were developed to support safe medication ordering, alerting prescribers to potential unsafe interactions such as drug-drug, drug-allergy, and dosing errors. This study uses a sociotechnical framework to understand the relationship between primary care prescribers’ safety work and CDS. Prescribers described the usefulness of CDS but also noted alert fatigue.
Liberman AL, Wang Z, Zhu Y, et al. Diagnosis (Berl). 2023;10:235-241.
Symptom–Disease Pair Analysis of Diagnostic Error (SPADE) is a framework to measure diagnostic errors using existing databases, such as electronic health records or administrative claims. The original developers of the SPADE framework provide additional guidance on types of comparator groups, how to select the appropriate group, and what inferences can be drawn from the analysis.
Duffy C, Menon N, Horak D, et al. JAMA Netw Open. 2023;6:e237621.
Safety-II is a proactive approach to improving patient safety by focusing on what goes right in healthcare. This study describes the use of a novel tool and activity, One Safe Act (OSA), to capture activities performed by perioperative staff that keep patients safe. Eight themes emerged, with the most common theme being routines the staff “always” performed, followed by confirming resource availability.
Quan SF, Landrigan CP, Barger LK, et al. J Clin Sleep Med. 2023;19:673-683.
Fatigue and sleep deprivation among healthcare workers can increase the risk of errors. This prospective study including 60 attending surgeons from departments of surgery or obstetrics and gynecology at eight hospitals found that sleep deficiency was not associated with greater numbers of errors during procedures performed the next day. However, non-technical skill performance, situational awareness, and decision making were adversely associated with sleep deficiency.
Auerbach AD, Astik GJ, O’Leary KJ, et al. J Gen Intern Med. 2023;38:1902-1910.
COVID-19 ushered in new diagnostic challenges and changes in care practices. In this study conducted during the first wave of the pandemic, charts for hospitalized adult patients under investigation (PUI) for COVID-19 were reviewed for potential diagnostic error. Diagnostic errors were identified in 14% of cases; patients with and without diagnostic errors were statistically similar and errors were not associated with pandemic-related change practices.
… J Hosp Med … I-PASS is a structured handoff tool to enhance communication during patient transfers and improve … adverse events and improved key handoff elements (e.g., frequency of handoffs with high verbal quality) across …
Okoli J, Arroteia NP, Ogunsade AI. Leadersh Health Serv (Bradf Engl). 2023;36:186-199.
… COVID-19 pandemic, leaders around the world were forced to rapidly made decisions with limited knowledge of the … and the media highlights three cognitive antecedents to crisis leadership failures: 1) ignoring the precautionary principle (e.g., “better safe than sorry”), 2) the illusion of control, …
Laing L, Salema N-E, Jeffries M, et al. PLoS ONE. 2022;17:e0275633.
Previous research found that the pharmacist-led IT-based intervention to reduce clinically important medication errors (PINCER) can reduce prescription and medication monitoring errors. This qualitative study explored patients’ perceived acceptability of the PINCER intervention in primary care. Overall perceptions were positive, but participants noted that PINCER acceptability can be improved through enhanced patient-pharmacist relationships, consistent delivery of PINCER-related care, and synchronization of medication reviews with prescription renewals.
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.
Hunter J, Porter M, Williams B. Australas Emerg Care. 2023;26:96-103.
… technicians (EMT) participated in a video simulation to assess their SA at each of the three stages. Quantitative … aware during the simulation. … Hunter J, Porter M, Williams B. A novel study of situational awareness among …