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.
Kepner S, Bingman C, Jones RM. Patient Saf. 2023;5:20-31.
Healthcare-associated infections remain a patient safety issue at long-term care facilities. Based on incident data from the Pennsylvania Patient Safety Reporting System (PA-PSRS), this analysis found that healthcare-associated infections in long-term care settings increased by 12.5% between 2021 and 2022; over half of this increase is due to an increase in respiratory and gastrointestinal infections.
Pennsylvania requires all acute care facilities to report incidents and serious events to the Pennsylvania Patient Safety Reporting System (PA-PSRS). This report compiles reports submitted in 2022 and compares results to previous years. There was a decrease in the total number of reports submitted, but serious and high harm events increased. The most frequently reported event continues to be Error Related to Procedure/Treatment/Test followed by Complication of Procedure/Treatment/Test, Medication Error, and Fall.
Bocknek L, Kim T, Spaar P, et al. Patient Safety. 2022;4:39-47.
Duplicate medication orders, defined as orders for two or more identical medications or same therapeutic class, can result in serious complications if they reach the patient. This study examined the error type (same medication, therapeutic class, or order), when they were recognized, and factors contributing to the error. Importantly, of duplicate orders in the same therapeutic class, the three most common medications were anti-coagulants, a high-risk medication.
Kepner S, Adkins JA, Jones RM. Patient Saf. 2022;4:6-17.
Residents at long-term care facilities are at increased risk for healthcare-associated infections. Using 2021 data from the Pennsylvania Patient Safety Reporting System (PA-PRS), this study characterized healthcare-associated infections (HAIs) occurring at long-term care facilities. Researchers found that HAIs occurring at long-term care facilities decreased, but it is unknown whether this is reflective of fewer infections or poor reporting practices at long-term care facilities, or both.
Taylor M, Reynolds C, Jones RM. Patient Safety. 2021;3:45-62.
Isolation for infection prevention and control – albeit necessary – may result in unintended consequences and adverse events. Drawing from data submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS), researchers explored safety events that impacted COVID-19-positive or rule-out status patients in insolation. The most common safety events included pressure injuries or other skin integrity events, falls, and medication-related events.
Taylor M, Kepner S, Gardner LA, et al. Patient Saf. 2020;2:16-27.
To assess the impact of COVID-19 on patient harm and potential areas of improvement for healthcare facilities, the authors analyzed data reported to one state’s adverse event reporting system. The authors identified 343 adverse events between January 1 and April 15, 2020. The most common factors associated with patient safety concerns in COVID-19-related events involved laboratory testing, process/protocol (e.g., staff failed to use sign-in sheets to monitor interactions with COVID-19 positive patients), and isolation integrity.
Gleason KT, Jones RM, Rhodes C, et al. J Patient Saf. 2021;17:e959-e963.
This study analyzed malpractice claims to characterize nursing involvement in diagnosis-related (n=139) and failure-to-monitor malpractice (n=647) claims. The most common contributing factors included inadequate communication among providers (55%), failure to respond (41%), and documentation failures (28%). Both diagnosis-related and physiologic monitoring cases listing communication failures among providers as a contributing factor were associated with a higher risk of death (odds ratio [OR]=3.01 and 2.21, respectively). Healthcare organizations need to take actions to enhance nurses’ knowledge and skills to be better engage them in the diagnostic process, such as competency training and assessment.
Schuerer DJE, Nast PA, Harris CB, et al. J Am Coll Surg. 2006;202:881-887.
This Agency for Healthcare Research and Quality (AHRQ)–supported study demonstrated that implementation of a card-based reporting system in place of an existing and underused online one increased reporting rates among both physicians and nurses. Investigators provided education prior to introduction of the new card reporting system as they introduced it, removed it, and reintroduced it to determine the effectiveness. Physician reporting dropped to zero after the card was removed and rose to peak levels after reintroduction. The authors also discuss the differences in the reports themselves, which suggested physicians more frequently report events that caused harm. Given the emphasis on reporting systems, the authors suggest this as an alternative mechanism to encourage reporting from physicians, a group very involved in patient care but infrequently participating in the event reporting process. A past survey study described physician perception of hospital safety and barriers to incident reporting.