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 872 Results

Prosocial voice in the hierarchy of healthcare professionals: the role of emotions after harmful patient safety incidents.

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Richmond JG, Burgess N. J Health Organ Manag. 2023;Epub Feb 28.

Healthcare professionals who are involved in patient safety incidents can experience psychological distress. Using three case examples from surgery, urology, and maternity care, this study explored the emotional experience of healthcare professionals involved in patient safety incidents. The authors discuss the importance of providing support for recovery after involvement in a patient safety incident and protecting professionals from workplace pressures.

Difficult diagnosis in the ICU: making the right call but beware uncertainty and bias.

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Pisciotta W, Arina P, Hofmaenner D, et al. Anaesthesia. 2023;78:501-509.

A 2012 review estimated that diagnostic errors in the intensive care unit (ICU) may contribute to up to 8% of patient deaths. This narrative review identifies common causes of diagnostic error (e.g., cognitive bias) and suggests a diagnostic framework. Cognitive de-biasing strategies and increasing time spent with the patient are recommended as strategies for reducing diagnostic errors in this vulnerable patient population.

Undertaking risk and relational work to manage vulnerability: acute medical patients' involvement in patient safety in the NHS.

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Sutton E, Martin G, Eborall H, et al. Soc Sci Med. 2023;320:115729.

Patient engagement is cornerstone to safe care initiatives. This qualitative study including 28 acute care patients explored how patients contribute to safety and highlight the importance of reassurance and vigilance.

Critical care teamwork in the future: the role of TeamSTEPPS in the COVID-19 pandemic and implications for the future.

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Terregino CA, Jagpal S, Parikh P, et al. Healthcare (Basel). 2023;11:599.

The COVID-19 pandemic dramatically changed healthcare delivery and impacted the ways healthcare teams function. Using interprofessional focus groups, this study explored the perspectives of medical intensive care unit (MICU) team members on the role of TeamSTEPPS® during the first year of the COVID-19 pandemic. Participants discussed how TeamSTEPPS® impacted teamwork and communication through shared mental models, trust, role definition, and effective briefing/debriefing and transitions of care strategies. Participants also identified several challenges to TeamSTEPPS® implementation related to the MICU environment, the ongoing pandemic, power dynamics, and patient acuity.

The Leapfrog Hospital Survey.

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Leapfrog Group.

This website offers resources related to the Leapfrog Hospital Survey investigating hospitals' progress in implementing specific patient safety practices. Updates to the survey include increased time allotted to complete computerized provider order entry evaluation, staffing of critical care physicians on intensive care units, and use of tools to measure safety culture. Reports discussing the results are segmented into specific areas of focus such as health care-associated infections and medication errors. The 2023 survey session opens April 1, 2023.

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Value and Patient Safety

March 8, 2023

Value as an element of patient safety is emerging as an approach to prioritize and evaluate improvement actions. This library highlights resources that explore the business case for cost effective, efficient and impactful efforts to reduce medical errors.

Association between unmet nonmedication needs after hospital discharge and readmission or death among acute respiratory failure survivors: a multicenter prospective cohort study.

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Bose S, Groat D, Dinglas VD, et al. Crit Care Med. 2023;51:212-221.

Medication discrepancies at discharge are a known contributor to hospital readmission, but nonmedication needs may also contribute. In this study, 200 survivors of acute respiratory failure were followed up 7-28 days post discharge to assess unmet nonmedication discharge needs (i.e., durable medical equipment, home health services, follow-up medical appointments). Nearly all patients had at least one unmet need, but this was not associated with hospital readmission or mortality within 90 days.

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.

Paediatric family activated rapid response interventions; qualitative systematic review.

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Cresham Fox S, Taylor N, Marufu TC, et al. Intensive Crit Care Nurs. 2023;2023:103363.

While many hospitals have rapid response teams (RRT) which can be activated by clinicians, only a few hospitals have also implemented programs which allow patients and families to activate RRT. This review identified 6 articles (5 interventions) with family-activated RRT in pediatric hospitals. The authors of the review conclude that family-activated RRT is a key component to family engagement and enhancing patient safety. Only one intervention was also available in a non-English language, which should be considered in future interventions.

Examination of impact of after-hours admissions on hospital resource use, patient outcomes, and costs.

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Skead C, Thompson LH, Kuk H, et al. Crit Care Res Pract. 2022;2022:4815734.

After-hours and weekend admissions to the hospital and intensive care units (ICU) have been linked to poor outcomes. This retrospective analysis compared outcomes among adult patients with daytime versus nighttime ICU admissions at one large Canadian medical center in between 2011 and 2015. Researchers found that overall mortality, but not ICU mortality, was higher among daytime admissions.

Interprofessional team collaboration and work environment health in 68 US intensive care units.

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Pun BT, Jun J, Tan A, et al. Am J Crit Care. 2022;31:443-451.

Team collaboration is an essential part of ensuring patient safety in acute care settings. This survey of care team members (including nurses, physicians, pharmacists, respiratory therapists, and rehabilitation therapists) assessed teamwork and collaboration across 68 intensive care units (ICUs). Teamwork and work environment were rated favorably but care coordination and meaningful recognition were rated least favorably.

Critical care clinicians' experiences of patient safety during the COVID-19 pandemic.

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Rosen A, Carter D, Applebaum JR, et al. J Patient Saf. 2022;18:e1219-e1225.

The COVID-19 pandemic had wide-ranging impacts on care delivery and patient safety. This study examined the relationship between critical care clinician experiences related to patient safety during the pandemic and COVID-19 caseloads during the pandemic. Findings suggest that as COVID-19 caseloads increased, clinicians were more likely to perceive care as less safe.

Implementation and facilitation of post-resuscitation debriefing: a comparative crossover study of two post-resuscitation debriefing frameworks.

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Kam AJ, Gonsalves CL, Nordlund SV, et al. BMC Emerg Med. 2022;22:152.

Debriefing after significant clinical events facilitates team-based communication, learning, and support. This study compared two post-resuscitation debriefing tools (Debriefing In Situ Conversation after Emergent Resuscitation Now [DISCERN] and Post-Code Pause [PCP]) following any intubation, resuscitation, or serious/unanticipated patient outcome in a children’s hospital. PCP was found to provide more emotional support and clinical learning, but there were no differences in the remaining categories.

State of Care.

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Newcastle Upon Tyne, UK: Care Quality Commission; October 2022.

This website provides access to an annual report that summarizes National Health Service hospital and social care performance across a range of care quality metrics at both the trust and service level. The 2022 report found most facilities to be generally operating at a effective level and basic performance was found to be high. However the report found substantial gaps in specialties such as maternity care and recognized staffing challenges that impact access and quality.

Exploring care left undone in pediatric nursing.

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Bagnasco A, Rossi S, Dasso N, et al. J Patient Saf. 2022;18:e903-e911.

Care left undone (also called missed care, unfinished care, and implicitly rationed care) is associated with lower perception of safety culture and increased adverse events. In this study, more than 2,200 pediatric nurses were asked about care tasks left undone in their most recent shift and a variety of environmental factors (e.g., perception of their work environment, risk of burnout). The most frequently omitted task was comfort/talk with patients, and the least frequently omitted task was pain management.

Miscommunication During the Interhospital Transport of a Critically Ill Child

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WebM&M Case August 31, 2022

A 2-year-old girl presented to her pediatrician with a cough, runny nose, low grade fever and fatigue; a nasal swab for SARS-CoV-2 and influenza was negative and lung sounds were clear. The patient developed a fever and labored breathing and was taken to the Emergency Department (ED) before being admitted to the hospital. She developed respiratory distress and clinically worsened over time until she developed respiratory failure requiring air transportation to the pediatric intensive care unit at a children’s hospital.

Medication errors in intensive care units: an umbrella review of control measures.

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Dionisi S, Giannetta N, Liquori G, et al. Healthcare (Basel). 2022;10:1221.

Medication errors are a global patient safety concern, particularly in high-risk areas like the intensive care unit. This umbrella review synthesizes medication interventions into two areas: systems (e.g., smart pumps) and processes (e.g., medication review). The authors highlight the importance of using multiple strategies when working to improve medication safety in the ICU.

Association between language use and ICU transfer and serious adverse events in hospitalized pediatric patients who experience rapid response activation.

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McDade JE, Olszewski AE, Qu P, et al. Front Pediatr. 2022;10:872060.

Language barriers can place patients at increased risk for adverse events and near misses. This retrospective cohort study found that rapid response team events for non-English speaking pediatric patients are more likely to result in transfer to the intensive care unit compared to English-speaking patients. However, researchers also found that increased use of interpreters can contribute to improved outcomes.

Undiagnosed and rare diseases in critical care: the role of diagnostic access.

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Bordini BJ. Crit Care Clin. 2022;38:159-171.

Rare diseases can present diagnostic challenges to clinicians. This article discusses how cognitive biases can impede diagnosis of rare conditions and strategies to improve diagnostic safety in critical care, such as diagnostic timeouts.

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Levkovich BJ, Orosz J, Bingham G, et al. BMJ Qual Saf. 2023;32:214-224.

Rapid response teams, also known as medical emergency teams (MET), are activated when a patient demonstrates signs of clinical deterioration to prevent transfer to intensive care, cardiac arrest, and death. MET activations were prospectively reviewed at two Australian hospitals to determine the proportion of activations due to medication-related harms and assess the preventability of the activation. 23% of MET activations were medication-related, and 63% of those were considered preventable. Most preventable activations were patients with hypertension, and prevention strategies should focus on these patients.

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