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.
Halvorson EE, Thurtle DP, Easter A, et al. Acad Pediatr. 2022;22:747-753.
Previous research has identified an association between patient weight and certain adverse events and patient safety threats, such as medication dosing errors and airway management. After analyzing data for pediatric patients discharged from a single children’s hospital, researchers in this study did not identify an association between patient body mass index (BMI) and the rate, severity, or preventability of adverse events.
The groundbreaking National Academy of Medicine report Unequal Treatment highlighted the pervasive nature of racial and ethnic disparities in United States health care. Racial and ethnic minorities experience more adverse events, including adverse drug events and hospital-acquired infections. Investigators used a pediatric global trigger tool to delineate disparities in safety events for a large, random sample of pediatric patients across 16 hospitals (4 hospitals in each US region). Latino children experienced nearly twice the rate of adverse events when compared with white children. Publicly insured children also had a higher adverse event rate. An accompanying editorial reviews study limitations and highlights the need to develop risk-prediction models for different types of adverse events.
Stockwell DC, Landrigan CP, Toomey SL, et al. Pediatrics. 2018;142:e20173360.
This study used a trigger tool (the Global Assessment of Pediatric Patient Safety) to examine temporal trends in adverse event rates at 16 randomly selected children's hospitals. Adverse event rates did not significantly change at either teaching or nonteaching hospitals from 2007 to 2012. Interestingly, nonteaching hospitals had lower error rates than teaching facilities, although the increased complexity of patients at teaching hospitals may account for this finding. The results of this study mirror those of a similar study conducted in adult hospitals from 2002 to 2007. An accompanying editorial notes that quality improvement collaboratives have achieved reductions in hospital-acquired conditions at children's hospitals and speculates that these discordant findings could be due to the fact that trigger tools are able to detect a broader range of adverse events and thus may provide a more accurate picture of safety. A WebM&M commentary discussed a preventable medication error at a children's hospital.
Stockwell DC, Landrigan CP, Schuster MA, et al. Pediatr Qual Saf. 2018;3:e081.
The Centers for Medicare and Medicaid Services (CMS) has successfully reduced preventable harm from hospital-acquired conditions (HACs) through financial penalties to hospitals. Hospitals nationwide have invested substantial resources in reducing the HACs on the CMS nonpayment list, raising concern about whether institutions may be neglecting other types of preventable harm. Researchers used an all-cause harm trigger tool to assess what proportion of harms that occurred at six children's hospitals were HACs versus harms excluded from the CMS list. Only 58 of 240 harms were considered HACs. Some common harms identified outside the scope of HACs were intravenous catheter infiltration, surgical complications, and pain. Prior WebM&M commentaries have discussed harms from hospital-acquired infections as well as the unintended consequences of public hospital quality reporting.
Sammer C, Miller S, Jones C, et al. Jt Comm J Qual Patient Saf. 2017;43:155-165.
Trigger tools seek to identify adverse events by flagging cases for review based on a particular data point (the "trigger"). Investigators, working through a Patient Safety Organization, sought an alternative to the widely used Institute for Healthcare Improvement Global Trigger Tool, one that would require less time and fewer resources. They developed a single, automated trigger encompassing a multitude of possible harms that could be implemented in real time. The most common harm identified by the novel trigger tool was hypoglycemia. The authors note that their tool detected more adverse events than the AHRQ Patient Safety Indicators. An accompanying editorial lauds this study as a step forward in efforts to harness the electronic health records to enhance patient safety through data analysis.
Detecting and measuring patient safety hazards remains challenging, but assessing the potential for a given safety problem to cause harm is even more difficult. Experts therefore sought to achieve consensus around an all-cause pediatric harm measurement tool using a modified Delphi process. They vetted 108 possible trigger tools that can indicate an incipient safety risk, including use of reversal agents for high-risk medications and diagnosis of health care–associated infections. After multiple rounds of discussion and evidence review, investigators produced a list of 51 triggers, which they plan to pilot test. The authors assert that this work is the first step toward identifying harm to pediatric patients in real-time.
Chaparro JD, Classen D, Danforth M, et al. J Am Med Inform Assoc. 2017;24:268-274.
Although computerized provider order entry (CPOE) for medications has reduced medication errors, it has also had unintended consequences. This simulation study used the validated Leapfrog evaluation tool to assess the safety of CPOE for medications for pediatric patients across multiple electronic health record (EHR) platforms. The investigators had clinicians familiar with the EHR enter prespecified unsafe orders into simulated patient records and note whether alerts or messages ensued. As demonstrated in prior work, many potentially unsafe medication orders did not lead to alerts. The authors report that repeated use of the tool led to improvement over time, which suggests the need for regular safety testing for EHRs after implementation.
Stockwell DC, Bisarya H, Classen D, et al. Pediatrics. 2015;135:1036-42.
Trigger tools are widely used as a means of detecting adverse events, but most of the existing triggers were developed and validated in adult populations. This study reports on the validation of a trigger tool for hospitalized pediatric patients, based on the Institute for Healthcare Improvement's Global Trigger Tool. In a retrospective chart review across six academic children's hospitals, the tool identified harm in 40% of admissions—a proportion comparable to a similar study in adult inpatients. Nearly half of these incidents were considered preventable. Other studies using slightly different pediatric trigger tools have found a lower incidence of adverse events. The use of trigger tools was discussed in a previous AHRQ WebM&M perspective.
Stockwell DC, Kirkendall E, Muething S, et al. J Patient Saf. 2013;9:203-10.
This study investigated the use of an automated adverse event detection system at two academic children's hospitals. Similar to prior studies, the automated triggers detected many more events than voluntary incident reporting systems.
Stockwell DC, Kane-Gill SL. Crit Care Med. 2010;38:S117-25.
This study reviewed the literature on different error surveillance systems and highlights what each system—such as chart review, trigger tools, and incident reporting systems—offers to organizational improvement efforts.