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.
Kappes M, Romero‐García M, Delgado‐Hito P. Int Nurs Rev. 2021;68:471-481.
Healthcare professionals who experience negative physical, psychological, or behavioral responses following an adverse event may be referred to as “second victims.” This review describes personal and organizational support strategies as well as barriers faced by second victims who are seeking support. The authors recommend further evaluation of support programs and implementation of support programs in Latin America.
Della Torre V, E. Nacul F, Rosseel P, et al. Anaesthesiol Intensive Ther. 2021;53:265-270.
Human factors (HF) is the interaction between workers, equipment, and the environment. The COVID-19 pandemic has accelerated the adoption of HF in intensive care units across the globe. This paper expands on the core concepts of HF and proposes the additional key concepts of agility, serendipity, innovation, and learning. Adoption of these HF concepts by leadership and staff can improve patient safety in intensive care units in future pandemics and other crisis situations.
Clinical pharmacist involvement has improved medication safety in several clinical areas. Using the therapeutic outcome monitoring (TOM) method, pharmacists in this study identified 43 negative outcomes associated with oral chemotherapy medication and performed 81 pharmaceutical interventions. The TOM method increased patient safety by improving the use of medications.
Dutra CK dos R, Guirardello E de B. J Adv Nurs. 2021;77:2398-2406.
This cross-sectional study describes the relationship between nurse work environment and missed nursing care, safety culture, and job satisfaction. Nurses who perceived a positive work environment reported reduced reasons for missed nursing care, an improved safety culture, and increased job satisfaction. Reasons for missed care were primarily related to lack of leadership support and resources. Nurse managers can increase perception of a positive work environment by providing additional support and adequate human and material resources.
Carvalho IV, Sousa VM de, Visacri MB, et al. Pediatr Emerg Care. 2021;37:e152-e158.
This study sought to determine the rate of pediatric emergency department (ED) visits due to adverse drug events (ADE). Of 1,708 pediatric patients, 12.3% were admitted to the ED due to ADEs, with the highest rates of admission due to neurological, dermatological, and respiratory medications. The authors recommend the involvement of clinical pharmacists to prevent and identify ADEs in the pediatric population, particularly through education of children’s caregivers and health professionals.
Tejos R, Navia A, Cuadra A, et al. Aesthetic Plast Surg. 2020;44:1926-1928.
Using a case of mislabeled lab specimens as an example, this article highlights the impact of the COVID-19 pandemic on the delivery of healthcare services and the role of human factors in identifying and preventing medical errors.
Camporesi A, Díaz‐Rubio F, Carroll CL, et al. J Paediatr Child Health. 2020;56:1010-1012.
This commentary discusses changes in critical care practice as a response to COVID-19, and the potential for iatrogenic harm to children when diverting from evidence-based medicine during the pandemic crisis.
Using a social and behavioral sciences perspective, the authors present insights for aligning behavior with recommendations from experts for managing the COVID-19 pandemic and its impact. Topics include threat perception, leadership, individual and collective interests, science communication, social context, and stress and coping.
Tartari E, Saris K, Kenters N, et al. PLoS One. 2020;15.
Presenteeism among healthcare workers can lead to burnout and healthcare-associated infections, but prior research has found that significant numbers of healthcare workers continue to work despite having influenza-like illness. This study surveyed 249 healthcare workers and 284 non-healthcare workers from 49 countries about their behaviors when experiencing influenza-like illness between October 2018 and January 2019. Overall, 59% of workers would continue to work when experiencing influenza-like illness, and the majority of healthcare workers (89.2-99.2%) and non-healthcare workers (80-96.5%) would continue to work with mild symptoms, such as a mild cough, fatigue or sinus cold. Fewer non-healthcare workers (16.2%) than healthcare workers (26.9%) would continue working with fever alone.
Sodré Alves BMC, de Andrade TNG, Cerqueira Santos S, et al. J Patient Saf. 2021;17:e1-e9.
This systematic review analyzed five studies discussing adverse events due to medical errors involving high-alert medications. The authors estimated the pooled prevalence at 16.3%, but the included studies reported a wide variation in prevalence (from 3.8% to 100%). The studies also reported a wide range in error severity – up to 19.2% were considered moderate, up to 15.4% were considered serious, and up to 1.9% were considered lethal. The most common medication administration errors involved insulin, potassium chloride, and epoprostenol.
Mamede S, de Carvalho-Filho MA, de Faria RMD, et al. BMJ Qual Saf. 2020;29:550-559.
There is uncertainty about the effectiveness of cognitive debiasing in reducing bias that can contribute to diagnostic error. Instead of focusing on the process of reasoning, this study examined whether an intervention directed at refining knowledge of a cluster of related disease can ‘immunize’ physicians against bias. Ninety-one internal medicine residents in Brazil were randomized to one of two sets of vignettes (reflecting diseases associated with either chronic diarrhea or jaundice) and compared/contrasted alternative diagnoses. After residents encountered one case of a disease, non-immunized residents twice as likely to give that incorrect diagnosis to a different (but similar) disease, resulting in a 40% decrease in diagnostic accuracy between immunized and non-immunized physicians.
Barbanti-Brodano G, Griffoni C, Halme J, et al. Eur Spine J. 2019.
Checklists are one tool for improving communication and reducing risk of adverse outcomes. The World Health Organization Surgical Safety Checklist has been previously studied in various surgical specialties; this study sought to determine its effectiveness in spinal surgeries. The authors conducted a retrospective analysis comparing the incidence of complications pre-checklist and post-checklist in a single center and found a significant reduction in the overall incidence of complications after the introduction of the checklist.
Lemos C de S, Poveda V de B. J Perianesth Nurs. 2019;34:978-998.
This integrative review examined the factors contributing to perioperative adverse events resulting from anesthesia. Researchers found that both active errors, such as medication errors or inattention, and latent errors, such as communication failures, contributed to adverse events.
Garcia C de L, de Abreu LC, Ramos JLS, et al. Medicina (Kaunas). 2019;55:553.
New meta-analysis on potential impacts of provider burnout concludes a relationship exists between high levels of burnout—from factors such as high workload and ineffective interpersonal relationships—and worsening patient safety.
Frid S, Zapico V, Mansilla A, et al. Stud Health Technol Inform. 2019;264:581-585.
Clinical provider order entry (CPOE) and clinical decision support systems (CDSS) are intended to enhance medication safety by reducing errors associated with prescription drugs. This study evaluated a tool allowing pharmacists to record errors or near misses, such as medication omission or unjustified medication stops, and communicate those events to the provider. Although only 29% of physicians accepted the pharmacist’s recommendations, these communicated events led to the provider following 112 recommended changes, which was an acceptance rate of 58%.
Lermontov SP, Brasil SC, de Carvalho MR. Cancer Nurs. 2019;42:365-372.
Bone marrow transplantation requires complex drug therapy management. This systematic review identified 11 studies reporting both medication prescription and administration errors, as well as issues such illegible writing, polypharmacy, absence of medication reconciliation, and lack of patient education. These errors resulted in a variety of adverse events. The review identified several prevention measures that can be implemented at the provider-level or systems-level (e.g., computerized prescribing systems).
Castro-Avila A, Bloor K, Thompson C. J Health Serv Res Policy. 2019;24:182-190.
In the United States, unannounced accreditation inspections are deployed extensively to evaluate hospital safety. This interrupted time-series analysis found that enhanced accreditation procedures in the United Kingdom did not improve rates of either pressure ulcers or falls. In a PSNet interview, the president of The Joint Commission discussed how accrediting bodies can help achieve high reliability.
de Araújo BC, de Melo RC, de Bortoli MC, et al. Front Pharmacol. 2019;10:439.
Prescribing errors are common and can result in patient harm. This review summarizes four key options to reduce prescribing errors: prescriber education, effective use of computerized alert systems at the clinical interface, use of tools and guidance to inform practice, and multidisciplinary teams that include pharmacists.
Tschandl P, Codella N, Akay BN, et al. Lancet Oncol. 2019;20:938-947.
Machine learning may have the potential to improve clinical decision-making and diagnosis. In this study, machine-learning algorithms generally performed better than human experts in accurately diagnosing 7 types of pigmented skin lesions and the top 3 algorithms performed better than the 27 physicians.
Johnston BE, Lou-Meda R, Mendez S, et al. BMJ Glob Health. 2019;4.
Medical errors are a concern across the economic spectrum worldwide. This commentary describes an educational effort to develop champions to lead patient safety, quality improvement, and infection control initiatives in health systems in low- and middle-income countries. The authors highlight the importance of contextualizing training to consider local needs and resources.
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