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.
Fu BQ, Zhong CCW, Wong CHL, et al. Int J Health Policy Manag. 2023;12:7089.
Peri-discharge interventions aim to reduce potential adverse events that can arise during and after hospital discharge. This systematic review of 13 qualitative studies identified common barriers and facilitators to implementing peri-discharge interventions. Frequently cited barriers included limited resources, poor team communication, and complicated intervention processes; common facilitators included leadership support, a positive organizational culture, and financial penalties.
Kim RG, An VVG, Lee SLK, et al. Orthop Traumatol Surg Res. 2023;109:103299.
Overlapping surgery, where “critical” portions of surgery are performed sequentially in separate operating rooms, is used to increase efficiency and number of procedures performed each day. This systematic review and meta-analysis was performed to determine differences in risk of complications between overlapping surgery (OS) and non-overlapping surgery (NOS) in total hip and total knee arthroplasty. Consistent with prior studies and reviews, there were no significant differences in adverse events or complications between OS and NOS. The authors stress that informed consent and patient education prior to OS is critically important.
Black GB, Lyratzopoulos G, Vincent CA, et al. BMJ. 2023;380:e071225.
Primary care often initiates a diagnostic process that is vulnerable to miscommunication, uncertainty, and delay. This commentary examines how cancer diagnosis delay in primary care occurs. The authors suggest a systems approach targeting interconnected process elements including enhanced use of information technology to help with monitoring and care coordination to realize and sustain improvement.
Vacheron C-H, Acker A, Autran M, et al. J Patient Saf. 2023;19:e13-e17.
Wrong-site, wrong-procedure, and wrong-patient errors (WSPEs) are serious adverse events. This retrospective analysis of medical liability claims data examined the incidence of WSPEs in France between 2007 and 2017. During this ten-year period, WSPEs accounted for 0.4% of all claims. Procedures on the wrong organ were most common (44%), followed by wrong side (39%), wrong person (13%) and wrong procedure (4%). The researchers found that the average number of WSPEs decreased after implementation of a surgical checklist.
Fröding E, Vincent C, Andersson-Gäre B, et al. Arch Suicide Res. 2022;Epub Oct 19.
Earlier research shows many investigations into suicide deaths are conducted to fulfill regulatory requirements, rather than to improve suicide-prevention interventions. This review identified six problems with investigations (e.g., failure to consider deeper system perspective) and proposed a new model of investigation which considers suicide a patient harm.
Schilling S, Armaou M, Morrison Z, et al. PLoS ONE. 2022;17:e0272942.
Effective teamwork is critical in acute and intensive care settings. This systematic review of reviews and thematic analysis identified four key factors that frame the evidence on interprofessional teams in acute and intensive care settings – (1) team internal procedures and dynamics, such as cohesion, organizational culture, and leadership influence; (2) communicative processes; (3) organizational and team-extrinsic influences, such as team composition, hierarchy, and interprofessional dynamics, and; (4) team outcomes, including both patient and staff outcomes.
Lester CA, Flynn AJ, Marshall VD, et al. J Am Med Inform Assoc. 2022;29:1471-1479.
Although e-prescribing has improved the safety of medication ordering, preventable errors persist. This study analyzed product descriptions (ingredient, strength, dose form) of more than 10 million e-prescriptions. Results show a wide variety in the way drug product descriptions are entered into e-prescription programs (e.g., 707 variants for “oral tablet” such as tablet, tab, po tab). Poor standardization of terminology in e-prescription programs can lead to incorrect medication order and patient confusion.
Fear of criminal liability may inhibit clinicians from reporting medical errors, thereby reducing opportunities for learning. This commentary discusses recent legal actions brought against clinicians, including Tennessee nurse RaDonda Vaught, and the negative impact such actions may have on the longstanding disclosure movement.
Powell ES, Bond WF, Barker LT, et al. J Patient Saf. 2022;18:302-309.
Telehealth is increasingly used to connect rural hospitals with specialists in other areas and can improve patient outcomes. This study found that in situ simulation training in rural emergency departments resulted in small increases in the use of telemedicine for patients presenting with sepsis and led to improvements in sepsis process care outcomes.
Alboksmaty A, Beaney T, Elkin S, et al. Lancet Digit Health. 2022;4:e279-e289.
The COVID-19 pandemic led to a rapid transition of healthcare from in-person to remote and virtual care. This review assessed the safety and effectiveness of pulse oximetry in remote patient monitoring (RPM) of patients at home with COVID-19. Results show RPM was safe for patients in identifying risk of deterioration. However, it was not evident whether remote pulse oximetry was more effective than other virtual methods, such as virtual visits, monitoring consultations, or online or paper diaries.
Blijleven V, Hoxha F, Jaspers MWM. J Med Internet Res. 2022;24:e33046.
Electronic health record (EHR) workarounds arise when users bypass safety features to increase efficiency. This scoping review aimed to validate, refine, and enrich the Sociotechnical EHR Workaround Analysis (SEWA) framework. Multidisciplinary teams (e.g. leadership, providers, EHR developers) can now use the refined SEWA framework to identify, analyze and resolve unsafe workarounds, leading to improved quality and efficiency of care.
Wade C, Malhotra AM, McGuire P, et al. BMJ. 2022;376:e067090.
The role of healthcare disparities in patient safety is an emerging priority. This article summarizes disparities in preventable harm and outlines solutions to reducing inequalities in patient safety at the individual-, leadership-, and system-levels, such as identifying clear chains of accountability for adverse events and improving incident measurement and analysis specific to marginalized patient groups.
Barten DG, Klokman VW, Cleef S, et al. Int J Emerg Med. 2021;14:49.
External disaster training and preparedness has been the focus of previous research. This case series and review focus on internal disasters in emergency departments (e.g., structural damage, fire, cyberattacks).
Cecil E, Bottle A, Majeed A, et al. Br J Gen Pract. 2021;71:e547-e554.
… Br J Gen Pract … There has been an increased focus on patient … incidence of emergency hospital admission within 3 days of a visit with a GP with missed sepsis, ectopic pregnancy , … emergency hospital admission. … Cecil E, Bottle A, MajeedA, et al. Factors associated with potentially missed …
Abraham P, Augey L, Duclos A, et al. J Patient Saf. 2021;17:e615-e621.
Patient misidentification errors are common and potentially catastrophic. Patient identification incidents reported in one hospital were examined to identify errors and contributory factors. Of the 293 reported incidents, the most common errors were missing wristbands, wrong charts or notes in files, administrative issues, and wrong labeling. The most frequent contributory factors include absence of patient identity control, patient transfer, and emergency context.
… JAMA Netw Open … Discharge from the hospital represents a vulnerable time for patients. This systematic review … and increased adherence to treatment regimen. … Becker C, Zumbrunn S, Beck K, et al. JAMA Netw Open . …
… J Surg Educ … Balancing resident autonomy and supervision is … chief resident surgery service is safe and can serve as a model to enhance resident autonomy during training. … … chief resident general surgery service safe for patients? J Surg Educ. Epub 2021 Aug 4. doi: 10.1016/j.jsurg.2021.07.005 …
Wu AW, Vincent CA, Shapiro DW, et al. J Patient Saf Risk Manag. 2021;26:93-96.
… J Patient Saf Risk Manag … The July effect is a phenomenon that presumably results in poor care due to the … to provide the safest care possible. … Wu AW, VincentC, Shapiro DW, et al. Mitigating the July effect. J Patient …