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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 938 Results
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.
Roussel M, Teissandier D, Yordanov Y, et al. JAMA Intern Med. 2023;Epub Nov 6.
Overcrowding in the emergency department (ED) can result in long wait times to be seen or admitted, as well as placing patients at increased risk of adverse events. In this prospective study, researchers compared the risk of in-hospital mortality among older patients who spent a night in the ED waiting for admission to the hospital versus older patients who were admitted to the hospital before midnight. Findings indicate that patients who spent an overnight in the ED had a higher in-hospital mortality rate, increased risk of adverse events, and longer length of stay; this risk was exacerbated for patients with limited functional status.
Lowe JT, Leonard J, Dominguez F, et al. Diagnosis (Berl). 2023;Epub Oct 6.
Non-English primary language (NEPL) patients may encounter barriers navigating the healthcare system and communicating with providers. In this retrospective study, researchers used the Safer Dx tool to explore differences in diagnostic errors among NEPL versus English-proficient (EP) patients. Among 172 patients who experienced a diagnostic error, the proportion was similar among EP and NEPL groups and NEPL did not predict higher odds of diagnostic error.
Grace MA, O'Malley R. Simul Healthc. . 2023;Epub Sep 19.
In situ simulation can reveal latent safety threats before they cause harm. This review identified 15 studies of in situ simulations conducted in the emergency department including simulations conducted prior to opening new facilities and to address emerging COVID-19 concerns. The most commonly identified safety threats were related to equipment and team communication.
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.
WebM&M Case October 31, 2023

A 2-year-old girl presented to the emergency department (ED) with joint swelling and rash following an upper respiratory infection. After receiving treatment and being discharged with a diagnosis of allergic urticaria, she returned the following day with worsening symptoms. Suspecting an allergic reaction to amoxicillin, the ED team prepared to administer methylprednisolone. However, the ED intake technician erroneously switched the patient’s height and weight in the electronic health record (EHR), resulting in an excessive dose being ordered and dispensed.

Jala S, Fry M, Elliott R. J Clin Nurs. 2023;32:7076-7085.
Cognitive biases can impact the type of care a patient receives and their subsequent outcomes, particularly in the emergency department which operates under time and resource constraints. This review identified 18 studies on cognitive biases in emergency physicians and nurses. Most studies focused on implicit bias and on physicians. Of the five studies focused solely on nurses, all assessed bias in emergency department triage.
Harmon CS, Adams SA, Davis JE, et al. Appl Nurs Res. 2023;73:151724.
Electronic health records increase safety in many ways but are not without problems. In this survey, emergency department nurses reported that electronic health record (EHR) issues (downtime, workflow) negatively impacted patient safety such as documentation or orders placed on the wrong patient chart.
Michelson KA, McGarghan FLE, Waltzman ML, et al. Hosp Pediatr. 2023;13:e170-e174.
Trigger tools are commonly used to detect adverse events and identify areas for safety improvement. This study found that trigger tools using electronic health record-based data can accurately identify delayed diagnosis of appendicitis in pediatric patients in community emergency department (ED) settings.
Gupta AB, Greene MT, Fowler KE, et al. J Patient Saf. 2023;19:447-452.
As high workload and interruptions are known contributors to diagnostic errors, significant research has been conducted to understand and ameliorate the impact of these factors. This study examined the association between hospitalist busyness (i.e., number of admissions and pages), resource utilization, number of differential diagnoses, and the hospitalist's diagnostic confidence and subjective awareness. Increasing levels of busyness were associated with hospitalists reporting it was "difficult to focus on what is happening in the present" but had no effect on diagnostic confidence.
Arastehmanesh D, Mangino A, Eshraghi N, et al. J Emerg Med. 2023;65:e250-e255.
Characteristics inherent to the emergency department (ED), such as overcrowding and unfamiliar patients, make it susceptible to errors. This article describes a novel process for identification of ED errors by adding the question, "Would you have done something differently?" to the chart review process. Adding this question and requiring a detailed explanation of what they would have done differently allowed for differentiation between a true medical error and a judgment call that coincides with an adverse event. Near misses, adverse events, and adverse events attributable to error were significantly higher when reviewers would have done something differently.
Essa CD, Victor G, Khan SF, et al. Am J Emerg Med. 2023;73:63-68.
Emergency department triage nurses use their knowledge, experience, expertise, and critical thinking skills to prioritize patients by severity, ensuring the sickest patients are seen first. This study sought to identify cognitive biases that may negatively impact nurses' triage decision making. In a scenario describing a patient at Emergency Severity Index (ESI) level 1, the highest level, only 51% of nurses selected the cognitively unbiased triage response.
Kotagal M, Falcone RA, Daugherty M, et al. J Trauma Acute Care Surg. 2023;95:426-431.
Simulation can be used to identify latent safety threats (LSTs) when implementing new workflows or care locations. In this study, simulation scenarios were used to identify LSTs associated with the opening of a new emergency department and critical care area. The 118 identified threats involved equipment, structural or layout issues, resource concerns, and knowledge gaps. Failure mode and effects analysis informed an action plan to mitigate these threats.

Irving, TX: American College of Emergency Physicians; 2023.

Error disclosure is difficult yet important for patient and clinician psychological healing. This statement provides guidance to address barriers to emergency physician disclosure of errors that took place in the emergency room. Recommendations for improvement include the development of organizational policies that support error reporting, disclosure procedures, and disclosure communication training.
WebM&M Case September 27, 2023

This case describes an older adult patient with generalized abdominal pain who was eventually diagnosed with inoperable bowel necrosis. Although she appeared well and had stable vital signs, triage was delayed due to emergency department (ED) crowding, which is usually a result of hospital crowding. She was under-triaged and waited three hours before any diagnostic studies or interventions commenced. Once she was placed on a hallway gurney laboratory and imaging studies proceeded hastily.

WebM&M Case September 27, 2023

A 42-year-old man with a history of posttraumatic stress disorder (PTSD), alcohol use disorder and anxiety disorder, was seen in the emergency department (ED) after a high-risk suicide attempt by hanging. The patient was agitated and attempted to escape from the ED while on an involuntary psychiatric commitment. The ED staff treated him as a “routine boarder” awaiting an inpatient bed, with insufficiently robust behavioral monitoring.

Michelson KA, Bachur RG, Grubenhoff JA, et al. J Emerg Med. 2023;65:e9-e18.
Missed diagnosis in the emergency department can result in unplanned hospitalization due to complications from worsening symptoms. In this study, pediatric patients with and without missed emergency department diagnosis were compared to determine differences in outcomes and hospital utilization. Children with missed diagnosis of appendicitis or new-onset diabetic ketoacidosis experienced more complications, hospital days and readmissions; there was no difference for sepsis diagnosis.
Hose B-Z, Carayon P, Hoonakker PLT, et al. Appl Ergon. 2023;113:104105.
Health information technology (IT) usability continues to be a source of patient harm. This study describes the perspectives of a variety of pediatric trauma team members (e.g., pediatric emergency medicine attending, surgical technician, pediatric intensive care unit attending) on the usability of a potential team health IT care transition tool. Numerous barriers and facilitators were identified and varied across department and role.

Farnborough, UK: Healthcare Safety Investigation Branch; August 2023.

Handoffs between prehospital emergency medical services (EMS) providers and hospital emergency departments (EDs) can be suboptimal, which increases patient harm potential. This report examines National Health Service discharge delays. It suggests a systemic approach is needed to address flow and capacity factors that contribute to ineffective and unsafe interfacility discharge and transfer.