The PSNet Collection: All Content

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.

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Displaying 1 - 20 of 57 Results

The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department.

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WebM&M Case April 26, 2023

This case involves a procedural sedation error in a 3-year-old patient who presented to the Emergency Department with a left posterior hip dislocation. The commentary summarizes the indications and risks of procedural sedation in non-surgical settings and highlights the value of implementing system-wide safety protocols and practices to prevent medication administration errors during high-risk procedures.

Quality improvement initiative to decrease central line-associated bloodstream infections during the COVID-19 pandemic: a "zero harm" approach.

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Redstone CS, Zadeh M, Wilson M-A, et al. J Patient Saf. 2023;19:173-179.

Previous research has found that central line-associated blood stream infections (CLABSIs) increased during the COVID-19 pandemic. This article describes the development, implementation, and evaluation of a quality improvement initiative (QI) at one community health system in Canada to reduce CLABSIs between July 2019 and May 2022. The QI initiative included changes in six areas – organizational oversight and accountability, education and training, standardized central line processes, optimized central line equipment, improving data and reporting, and fostering a culture of safety. Over the study period, CLABSIs were reduced by 51% and the use of both central line insertion checklists and central line capped lumens increased.

Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation

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WebM&M Case March 15, 2023

A 72-year-old man was diagnosed with COVID-19 pneumonia and ileus, and admitted to a specialized COVID care unit. A nasogastric tube (NGT) was placed, supplemental oxygen was provided, and oral feedings were withheld. Early in his hospital stay, the patient developed hyperactive delirium and pulled out his NGT. Haloperidol was ordered for use as needed (“prn”) and the nurse was asked to replace the NGT and confirm placement by X-ray. The bedside and charge nurses had difficulty placing the NGT and the X-ray confirmation was not done.

Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure.

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WebM&M Case February 1, 2023

A 5-day old male infant was admitted to the pediatric intensive care unit (PICU) and underwent surgery to correct a congenital heart defect. The patient’s postoperative course was complicated Staphylococcus aureus bacteremia and other problems, requiring venoarterial extracorporeal membrane oxygenation (VA-ECMO) and subsequent cardiac procedures.

The safety of inpatient health care.

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Bates DW, Levine DM, Salmasian H, et al. New Engl J Med. 2023;388:142-153.

An accurate understanding of the frequency, severity, and preventability of adverse events is required to effectively improve patient safety. This study included review of more than 2,800 inpatient records from 11 American hospitals with nearly one quarter having at least one preventable or not preventable adverse event. Overall, approximately 7% of all admissions included at least one preventable event and 1% had a severity level of serious or higher.

Anesthesia outside of the OR: cause for patient safety concerns?

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DePeau-Wilson M. MedPage Today. January 13, 2023.

The use of anesthesia in ambulatory settings presents both advantage and risk to patients and clinicians. This article discusses evidence defining these issues. It suggests that improved collaboration with anesthesiologists represents opportunities for nonoperating room anesthesia safety.

Causes of adverse events in home mechanical ventilation: a nursing perspective.

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Lipprandt M, Liedtke W, Langanke M, et al. BMC Nurs. 2022;21:264.

Hospital-level care at home can reduce cost and hospital readmissions, but adverse events still occur at levels similar to hospitals. This study explored adverse events related to home mechanical ventilation (HMV), in order to categorize causes and recommend solutions. Interventions for nurses (e.g., checklists) and manufacturers (e.g., alarm design) may improve HMV.

ISMP Guidelines for Safe Medication Use in Perioperative and Procedural Settings.

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Plymouth Meeting, PA: Institute for Safe Medication Practices; 2022.

Medication errors associated with surgery and other invasive procedures can result in patient harm. This 10-element guidance suggests effective practices to address identified weaknesses in perioperative and procedural medication processes. Recommendations provided cover topics such as drug labeling, communication, and risk management.

Preventing patient positioning injuries in the nonoperating room setting.

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Moody A, Chacin B, Chang C. Curr Opin Anaesthesiol. 2022;35:465-471.

Hospital-acquired pressure injuries are considered a never event. This review presents strategies to prevent pressure injuries in the nonoperating room anesthesia (NORA) population (e.g., patients on ventilators). Proper positioning of the patient, with bolsters and padding, are illustrated.

A blueprint for success: implementation of the Center for Medicare and Medicaid Services mandated anesthesiology oversight for procedural sedation in a large health system.

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Abdelmalak BB, Adhami T, Simmons W, et al. Anesth Analg. 2022;135:198-208.

A 2009 CMS Condition of Participation (CoP) requires that a director of anesthesia services assume overall responsibility for anesthesia administered in the hospital, including procedural sedation provided by nonanesthesiologists. This article reviews the CoP as it relates to procedural sedation, lays out a framework for implementing this role, and describes challenges of implementation in a large health system.

Hospital-wide cardiac arrest in situ simulation to identify and mitigate latent safety threats.

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Bentley SK, Meshel A, Boehm L, et al. Adv Simul (Lond). 2022;7:15.

In situ simulations are an effective method to identify latent safety threats (LST). Seventy-four in situ cardiac arrest simulations were conducted in one hospital, identifying 106 unique LSTs. Four LSTs were deemed imminent safety threats and were immediately resolved following debrief; another 15 were prioritized as high-risk.

Management of Cardiac Arrest in Unconventional Locations.

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WebM&M Case May 16, 2022

This WebM&M describes two cases involving patients who became unresponsive in unconventional locations – inside of a computed tomography (CT) scanner and at an outpatient transplant clinic – and strategies to ensure that all healthcare teams are prepared to deliver advanced cardiac life support (ACLS), such as the use of mock codes and standardized ACLS algorithms.

A dynamic risk management approach for reducing harm from invasive bedside procedures performed during residency.

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Warm E, Ahmad Y, Kinnear B, et al. Acad Med. 2021;96:1268-1275.

Technical and procedural skills are an important emphasis of medical training. This article briefly summarizes the “as low as reasonably achievable” (ALARA) approach, which was developed for the nuclear industry and has been used in radiology. The authors outline how ALARA risk standards can be adapted by training program directors to measure procedural competency and assess and reduce bedside procedural risks.

Improving peripherally inserted central catheter appropriateness and reducing device-related complications: a quasiexperimental study in 52 Michigan hospitals.

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Chopra V, O'Malley M, Horowitz J, et al. BMJ Qual Saf. 2022;31:23-30.

Peripherally inserted central catheters (PICC) represent a key source of preventable harm. Using the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC), the authors sought to determine if the appropriateness of PICC use decreased related medical complications including catheter occlusion, venous thromboembolism, and central line-associated bloodstream infections. Use of MAGIC in 52 Michigan hospitals increased appropriate use of PICC lines and decreased medical complications. In a 2019 PSNet Perspective, Dr. Vineet Chopra described the development and implementation of MAGIC in Michigan hospitals.

A night in the hospital, from both ends of the stethoscope.

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Ofri D. New York Times. January 5, 2021.

Physicians have unique perspectives when exposed to health care delivery problems as patients themselves or as caregivers. This news story shares the author’s frustrations with the system of care observed during an overnight visit at the bedside of her daughter awaiting an emergency appendectomy. Her experience underscored the value of patients and families engaging in the safety of actions clinicians take when providing care.

One Bronchoscopy, Two Errors

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WebM&M Case January 1, 2019

Hospitalized in the ICU with hypoxic respiratory failure due to community-acquired pneumonia, an elderly man had increased pulmonary secretions on hospital day 2 for which the critical care provider decided to perform bedside bronchoscopy. Following the procedure, the patient was difficult to arouse, nearly apneic, and required intubation. The care team paused and discovered that after the patient had received 2 mg of intravenous midalozam, his IV line had been flushed with an additional 10 mg of the benzodiazepine, rather than the intended normal saline.

Nurses' perceived skills and attitudes about updated safety concepts: impact on medication administration errors and practices.

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Armstrong GE, Dietrich M, Norman L, et al. J Nurs Care Qual. 2016;32:226-233.

Medication administration errors are common and account for a significant fraction of medication errors. This study sought to assess how bedside nurses' reported attitudes and skills with safety practices affect medication administration errors. Researchers determined that system, local, and individual bedside nurse factors contribute to medication administration errors.

Errors, omissions, and outliers in hourly vital signs measurements in intensive care.

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Maslove DM, Dubin JA, Shrivats A, et al. Crit Care Med. 2016;44:e1021-e1030.

Vital signs remain a mainstay of monitoring for deterioration, and early identification of and rapid response to clinical deterioration is critical to preventing patient harm. This observational study used an automated technique to characterize vital sign measurement for nearly 50,000 intensive care unit stays. Investigators found that omission of vital sign recording occurred more than one third of the time. The analysis identified logically inconsistent blood pressure measurements, which suggested data-entry error. The data included a significant proportion of unusual, outlier vital sign values. Taken together, these results demonstrate important inaccuracy in vital sign documentation in the intensive care unit. The authors recommend seeking alternatives to hourly vital sign monitoring in order to optimize safety. A previous WebM&M commmentary discussed challenges in monitoring vital signs.

Implementing delivery room checklists and communication standards in a multi-neonatal ICU quality improvement collaborative.

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Bennett SC, Finer N, Halamek LP, et al. Jt Comm J Qual Patient Saf. 2016;42:369-76.

Checklists and debriefing improve patient safety across multiple care settings. In this quality improvement initiative, participating hospitals reported high levels of adherence and satisfaction to a protocol for neonatal resuscitation that included a checklist, briefings, and debriefings. The authors advocate for these safety processes to be included in neonatal resuscitation guidelines.

Use of quality indicators to compare point-of-care testing errors in a neonatal unit and errors in a STAT central laboratory.

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Cantero M, Redondo M, Martín E, et al. Clin Chem Lab Med. 2015;53:239-47.

In this study of a single neonatal unit, point-of-care testing resulted in many more quality errors compared to central laboratory testing. More than 45% of the point-of-care tests lacked appropriate patient identification, a problem the authors hope to fix by changing to a barcoding system in their hospital.

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