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 425 Results

The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis

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Patient Safety Innovation March 15, 2023

During a time of unprecedented patient volume and clinical uncertainty, a diverse team of health system administrators and clinicians within the University of Pennsylvania Health System quickly investigated, updated, and disseminated airway management protocols after several airway safety incidents occurred among COVID-19 patients who were mechanically ventilated. Based on this experience, the team created the I-READI framework as a guide for healthcare systems to prepare for and quickly respond to quality and safety crises.¹

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.

Surgical fire in the United States: 2000-2020.

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Grauer JS, Kana LA, Alzouhayli SJ, et al. Surgery. 2022;173:357-364.

Surgical fires, while rare, can result in the injury, permanent disability, or death of patients or healthcare workers. Between 2000 and 2020, 565 surgical fires resulting in injury were reported to the FDA’s Manufacturer and User Facility Device Experience (MAUDE) database. Fires were most likely to occur during upper aerodigestive tract and head and neck surgeries; these were also most likely to result in life-threatening injury.

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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.

The (commercialised) experience of operating: embodied preferences, ambiguous variations and explaining widespread patient harm.

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Ducey A, Donoso C, Ross S, et al. Sociol Health Illn. 2023;45:346-365.

Research has identified variations in treatment that are unlikely to be related to patient characteristics, such as region. In this study, surgeons describe their preferences for and experiences with a device which caused widespread harm to women and was ultimately recalled by several patient safety agencies: transvaginal mesh for the treatment of pelvic floor devices in women. Even when surgeons arrived at the same decision (to perform surgery or not), wide variations were observed during the decision-making process.

Examples of Medical Device Misconnections.

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Food and Drug Administration. February 23. 2023.

Mismatches of medical device connectors are known factors in therapeutic agent administration failures, despite efforts to redesign equipment and minimize their occurrence. This series of case studies drawn from reports submitted to the Food and Drug Administration illustrates a variety of misconnection scenarios to demonstrate situations that have a range of potential for patient harm.

Compendium of Strategies to Prevent HAIs in Acute Care Hospitals 2022.

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Infect Control Hosp Epidemiol. 2022-2023.

Health care–associated infections (HAIs) affect patients both during and after hospitalization. The use of patient safety methods as well as traditional infection control practices has resulted in significant successes in curbing HAIs such as central-line bloodstream infections. This set of practice guidelines will be developed and disseminated over the course of 2022-2023 to summarize preemptive actions and implementation strategies for prevention of HAIs.

Home medical device safety tops ECRI'S list of healthcare technology.

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Wicklund E. HealthLeaders. January 19, 2023.

Technologies both advance and challenge care safety. This article summarizes an annual analysis spotlighting health technology that may contribute to patient harm. Issues with home-based tools and single-use devices were underscored as priorities for improvement by both care organizations and equipment manufacturers.

Use of recalled devices in new device authorizations under the US Food and Drug Administration's 510(k) pathway and risk of subsequent recalls.

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Kramer DB, Yeh RW. JAMA. 2023;329:136-143.

The Food and Drug Administration (FDA) plays an important role in ensuring the safety of medical devices. In this cross-sectional study, researchers identified a high risk of future Class 1 FDA recall (the most serious recall designation, indicating serious risks to patient safety) among previously authorized devices (predicates) with prior Class 1 recalls.

Unsafe by design: infusion task reallocation and safety perceptions in U.S. hospitals.

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Pratt BR, Dunford BB, Vogus TJ, et al. Health Care Manage Rev. 2022;48:14-22.

Organizational pressures sometimes lead to redeployment or task reallocation such as shifting infusion tasks from specialty nurse teams to generalist nurses. This survey of nurses in the United States found that infusion task reallocation led to increased job demands and reduced resources, thereby contributing to lower perceived organizational safety.

Sources of nurse-sensitive inpatient safety improvement.

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Dynan L, Smith RB. Health Serv Res. 2022;57:1235-1246.

Nurses play a critical role in ensuring patient safety, and prior research has shown that better nurse-staffing ratios and nurse engagement can improve mortality rates. This study of nearly 300 Florida acute-care hospitals evaluated the effect of expenditures on continuing nurse education staffing ratios of several AHRQ Patient Safety Indicators (PSI). Increased spending on both improved outcomes in catheter-related blood stream infections, pressure ulcers, and deep vein thrombosis.

Barriers and facilitators to reporting medical device-related pressure ulcers: a qualitative exploration of international practice.

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Crunden EA, Worsley PR, Coleman SB, et al. Int J Nurs Stud. 2022;135:104326.

Hospital-acquired pressure ulcers, categorized as a never event, are underreported, particularly when related to medical devices. Interviews with experts in hospital-acquired pressure ulcers revealed four domains related to reporting: 1) individual health professional factors, 2) professional interactions, 3) incentives and resources, and 4) capacity for organizational change. Teamwork, openness, and feedback were seen as the main facilitators to reporting, and financial consequences was a contributing barrier.

Developing strategic recommendations for implementing smart pumps in advanced healthcare systems to improve intravenous medication safety.

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Sutherland A, Jones MD, Howlett M, et al. Drug Saf. 2022;45:881-889.

Intravenous (IV) medication smart pumps can improve medication administration, but usability issues can compromise safety. This article outlines strategic recommendations regarding the implementation of smart pump technology to improve patient safety. Recommendations include standardization of infusion concentrations, improving drug libraries using a human-centered approach, and increasing stakeholder engagement.

Pulse oximeters and their inaccuracies will get FDA scrutiny today. What took so long?

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McFarling UL. STAT. November 1, 2022.

Evidence is building to delineate the effect of systemic bias on care safety. This article recognizes the flaws of pulse oximeters on patients with darker skin, gaps in the literature base, and the work of regulatory bodies to consider redesign and regulation of the device to address bias.

National Healthcare Quality and Disparities Reports.

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Rockville, MD: Agency for Healthcare Research and Quality.

In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. The 2022 report discusses a decrease in life expectancy due to the COVID-19 pandemic. It also reviews the current status of special areas of interest such as maternity care, child and adolescent mental health, and substance abuse disorders.

Hospital-acquired conditions reduction program, racial and ethnic diversity, and Magnet designation in the United States.

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Boamah SA, Hamadi HY, Spaulding AC. J Patient Saf. 2022;18:e1090-e1095.

Medicare’s Hospital-Acquired Condition (HAC) Reduction Program financially incentivizes hospitals to reduce HAC rates and earlier research has shown hospitals in more diverse areas have higher odds of performing poorly. This study compares HAC reduction in Magnet and non-Magnet hospitals and examines potential racial and ethnic disparities. Similar to an earlier study, Magnet hospitals had significant improvements in methicillin-resistant Staphylococcus aureus (MRSA) rates, but not other HACs.

Intravenous smart pumps at the point of care: a descriptive, observational study.

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Giuliano KK, Blake JWC, Bittner NP, et al. J Patient Saf. 2022;18:553-558.

Intravenous (IV) smart pumps can improve medication administration safety, but usability issues can compromise that safety. This study compared actual use of smart pumps to the manufacturer’s requirements for operation. Adherence to requirements was low and the authors present several recommendations to smart pump manufacturers. The Institute for Safe Medication Practices issued guidelines for safe use of smart pumps that address several of these safety concerns.

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.

The hidden risk of wheelchair use.

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Quesenberry M. Patient Safety. 2022;4:6-9.

Medical devices intended to improve patient safety can unintentionally lead to patient harm. This patient safety alert draws attention to the risk of injury when hospital wheelchairs are used by staff, patients, or visitors who may not have training in safe use. Understanding the proper use of the wheelchair, particularly folding wheelchairs, is crucial to ensuring safety.

Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan.

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WebM&M Case September 28, 2022

This case describes a 20-year-old woman was diagnosed with a pulmonary embolism and occlusive thrombus in the right brachial vein surrounding a peripherally inserted central catheter (PICC) line (type, gauge, and length of time the PICC had been in place were not noted). The patient was discharged home but was not given any supplies for cleaning the PICC line, education regarding the signs of PICC line infection, or referral to home health services.

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