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 2302 Results

'Nobody cared': Women who have reported mistreatment while giving birth say CDC report validates their trauma. Advocates call for systemic change in treatment of pregnant people.

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Dwyer D, See P. ABC News. November 28, 2023.

Lack of respect for the concerns of patients and sensitivity to their situation detract from their safety and trust in the health care system. This story relates firsthand experience of maternal mistreatment of those harmed while receiving care.

Medication management of COVID-19 patients during transition to virtual models of care: a qualitative study.

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Hattingh HL, Edmunds C, Gillespie BM. J Pharm Policy Pract. 2023;16:127.

Remote or virtual patient care was an increasingly common strategy during the COVID-19 pandemic to keep patients safe and ensure adequate inpatient resources for patients unable to be cared for virtually. In this study, hospital physicians, pharmacists, and nurses described medication challenges associated with patients receiving virtual care (i.e., hospital-level care at home or hotel). Participants described challenges with lack of clarity on who is responsible for the patient's usual home medications, disruptions to typical workflow, and difficulties with transition from inpatient to virtual care.

Identifying and mapping measures of medication safety during transfer of care in a digital era: a scoping literature review.

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Leon C, Hogan H, Jani YH. BMJ Qual Saf. 2023;Epub Nov 3.

Errors associated with high-risk medications (HRM) like insulin and anticoagulants carry a greater risk for harm. The purpose of this scoping review was to identify measures evaluating the safety of HRM during transitions of care. Measures were mapped to frameworks (e.g., Donabedian) and whether measures were reactive, proactive, or real-time. The authors describe ways technology can improve how the measures are implemented.

'Corridor care' in the emergency department: managing patient care in non-clinical areas safely and efficiently.

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Williams C. Emerg Nurse. 2023;31:34-41.

Overcrowding in the emergency department (ED) and boarding can place patients at increased risk for adverse events. This article outlines how ED overcrowding occurs and provides several approaches to mitigate risks and enhance patient safety in overcrowded EDs, such as checklists, huddles, and resource allocation.

When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)!

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WebM&M Case November 30, 2023

A 67-year-old man with well-controlled type 2 diabetes mellitus underwent elective cardiac resynchronization and defibrillator device (CRT-D) implantation. The procedure was successful and he was discharged the next day with instructions to resume his prior medications, including empagliflozin. He presented to the emergency department the following day where he was diagnosed with euglycemic diabetic ketoacidosis (eDKA) and he was transferred to the intensive care unit (ICU) for insulin infusion.

The Risks of a Malpositioned Gastrostomy Tube and Poor Communication

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WebM&M Case November 29, 2023

This case describes a 55-year-old woman who sustained critical injuries after a motor vehicle crash and had a lengthy hospitalization. On hospital day 30, a surgeon placed a percutaneous endoscopic gastrostomy (PEG) tube in the intensive care unit (ICU) after computed tomography (CT) scan showed no interposed bowel between the stomach and the anterior abdominal wall. After the uncomplicated PEG placement, the surgeon cleared the patient’s team to advance tube feeds as tolerated.

Relationship of the nursing practice environment with the quality of care and patients' safety in primary health care.

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Lucas P, Jesus É, Almeida S, et al. BMC Nurs. 2023;22:413.

A poor work environment can have a negative impact on quality and safety of patient care. This study of primary care nurses in Portugal shows that better work practice environments are associated with higher quality of care, patient safety, and safety culture. Nursing foundations for quality of care and collegial nurse-physician relations were the highest rated survey dimensions.

The complexities of communication at hospital discharge of older patients: a qualitative study of healthcare professionals' views.

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Cam H, Wennlöf B, Gillespie U, et al. BMC Health Serv Res. 2023;23:1211.

When patients are discharged from the hospital, they (and their informal caregivers) are given copious amounts of information that must also be communicated to their primary care provider. This qualitative study of primary care and hospital physicians, nurses, and pharmacists highlights several barriers to complete and effective communication between levels of care, particularly regarding geriatric medication safety. Barriers include the large number of complex patients and incongruent expectations of responsibility of primary and hospital providers. Support systems, such as electronic health records, can both enable and hinder communication.

Prevented harm and cost avoidance with pharmacist intervention while utilizing a discharge medication reconciliation tool.

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Hoffman AM, Walls JL, Prusch A, et al. Am J Health Syst Pharm. 2023;Epub Oct 9.

Hospitals must balance costs associated with pharmacist medication reconciliation (e.g., salary) with prevented harm and cost avoidance (e.g., unreimbursed expenses resulting from medication error). This study found an estimate cost avoidance of $47,000 - $231,000 during one month in one hospital. The highest-risk, highest-cost classes were insulin, antithrombotics, and opioids. In resource-limited environments, focusing on the highest-cost classes could avoid significant cost and patient harm.

Talking about falls: a qualitative exploration of spoken communication of patients' fall risks in hospitals and implications for multifactorial approaches to fall prevention.

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McVey L, Alvarado N, Healey F, et al. BMJ Qual Saf. 2023;Epub Nov 8.

Reducing or preventing inpatient falls is a common focus of patient safety improvement efforts in hospitals. This study in three orthopedic and three geriatric wards describes multidisciplinary communication about falls prevention strategies. Risk assessments and categorization (e.g., high- or low-risk) were discussed in conjunction with strategies to focus on modifiable risk factors.

Perspectives on perioperative team-based morbidity and mortality conferences: a mixed-methods study.

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Samost-Williams A, Rosen R, Cummins E, et al. Jt Comm J Qual Patient Saf. 2023;Epub Oct 15.

Team-based morbidity and mortality conferences (TBMMs) involve multidisciplinary or interdisciplinary teams in discussions about complex cases and medical errors. This survey of 1,466 perioperative health care professionals found positive perceptions of TBMMs and traditional Morbidity and Mortality Conferences, but identified several barriers to effective implementation of TBMMs, including unsupportive leadership and fear of professional consequences.

Facilitators and barriers to the implementation of surgical safety checklist (SSC): an integrative review.

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Lim PJH, Chen L, Siow S, et al. Int J Qual Health Care. 2023;35:mzad086.

Surgical safety checklists (SCC) are utilized around the world, but checklist completion at the operating room level remains inconsistent. This review summarizes facilitators and barriers to completion. Resistance or endorsement at the individual surgeon level remains a significant factor in SSC completion. Early inclusion of frontline staff in evaluation and implementation supported increased use.

Effect of complementary interventions to redesign care on teamwork and quality for hospitalized medical patients: a pragmatic controlled trial.

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O’Leary KJ, Johnson JK, Williams MV, et al. Ann Intern Med. 2023;Epub Oct 31.

Teamwork is an essential component of ensuring high quality, safe healthcare. This article describes findings from the Redesigning SystEms to Improve Teamwork and Quality for Hospitalized Patients (RESET) study, which evaluated the impact of complementary interventions to redesign unit-based care (unit-based physician teams, nurse-physician co-leadership, interprofessional rounds, performance reports, patient engagement) on interprofessional teamwork and patient outcomes. Findings demonstrate improved teamwork climate scores among nurses (but not physicians), but researchers did not identify a significant impact on patient outcomes.

Identifying barriers and enablers for a robust independent second check of medication in adult intensive care.

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Milic V, Cameron L, Jones C. Br J Nurs. 2023;32:840-848.

Double checking of medication administration one strategy meant to reduce medication errors. In this study, 29 critical care nurses took part in a focus group exploring the barriers to double-checking during medication administration. Participants discussed several challenges, such as patient location (particularly for patients in isolation due to infection control measure), health IT limitations, and unclear roles and responsibilities.

Handoff tool improves transitions from the operating room to the neonatal intensive care unit.

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Gallois JB, Zagory JA, Barkemeyer B, et al. Pediatr Qual Saf. 2023;8:e695.

Structured handoff tools can improve situational awareness and patient safety. This study describes the development and implementation of a bespoke tool for handoffs from the operating room to the neonatal intensive care unit (NICU). While use remained inconsistent during the study period, the goal of 80% compliance was achieved and 83% surveyed staff agreed or strongly agreed that the handoff provided needed information, up from 21% before implementation.

Supporting nurses in acute and emergency care settings to speak up.

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Clarke-Romain B. Emerg Nurse. 2023;Epub Sep 19.

Delays in raising concerns in acute or emergency care can have tragic consequences. This commentary uses a case study to highlight barriers to speaking up and evidence-based tools nurses can use such as the CUS Tool and two-challenge rule. Training all healthcare staff in communication techniques can encourage speaking up and respectful responses.

React, reframe and engage. Establishing a receiver mindset for more effective safety negotiations.

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Barlow M, Watson B, Morse K, et al. J Health Organ Manag. 2023;Epub Sep 26.

Hierarchy and expected response may inhibit someone from speaking up about a safety concern. This study used two vignettes of a speaking up situation with randomization on speaker seniority, discipline (i.e., allied staff, nurse, physician), tone (i.e., accommodating or non-accommodating), and the presence of other people in the room. All participants were more likely to respond positively to the accommodating tone, but the impact of seniority varied by receiver's discipline.

On Patient Safety.

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Rickert J, Järvinen TLN, Lee MJ, et al. Clin Orthop Relat Res. 2013-2023.

This quarterly commentary explores a wide range of subjects associated with patient safety, such as the impact of disruptive behavior on teams, the value of apologies, and safety challenges inherent in clinician strike actions. Older materials are available online for free.

Intervention of pharmacist included in multidisciplinary team to reduce adverse drug event: a qualitative systematic review.

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Zaij S, Pereira Maia K, Leguelinel-Blache G, et al. BMC Health Serv Res. 2023;23:927.

An increasing strategy to reduce adverse drug events (ADE) is pharmacist medication review, typically involving other members of the care team. This qualitative review summarizes randomized studies of interventions with multidisciplinary care teams to reduce ADE. Most interventions were time-intensive (1- to 2-hours), including four steps (data collection, appraisal report, multidisciplinary medication review, follow up). Most teams consisted of a pharmacist, physician, and nurse, although some included other providers such as psychologists or social workers.

Identifying contributing factors associated with dental adverse events through a pragmatic electronic health record-based root cause analysis.

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Kalenderian E, Bangar S, Yansane A, et al. J Patient Saf. 2023;19:305-312.

Understanding factors that contribute to adverse events (AE) is key to preventing them from recurring. This study used an electronic trigger tool to identify potential AE in two dental practices. Of 439 charts reviewed, 13% contained at least one AE. The most common AE was post-procedural pain; the expert panel reported 21% of those AEs were preventable. Person-related factors (e.g., supervision, fatigue) were the most common contributing factors.

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