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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 1011 Results
Patient Safety Innovation May 31, 2023

Seeking a sustainable process to enhance their hospitals’ response to sepsis, a multidisciplinary team at WellSpan Health oversaw the development and implementation of a system that uses customized electronic health record (EHR) alert settings and a team of remote nurses to help frontline staff identify and respond to patients showing signs of sepsis. When the remote nurses, or Central Alerts Team (CAT), receive an alert, they assess the patient’s information and collaborate with the clinical care team to recommend a response.

Boudreaux ED, Larkin C, Vallejo Sefair A, et al. JAMA Psych. 2023;Epub May 17.
Patients who present to the emergency department (ED) with suicidal ideation can benefit from ED-initiated interventions, but interventions can be difficult to implement and maintain. This research builds on a 2013 study, describing the quality improvement (QI) methods used to implement the Emergency Department Safety Assessment and Follow-up Evaluation 2 (ED-SAFE 2) trial. The QI approach was successful in reducing death by suicide and suicide-related acute care during the study period.

Surana K. Pro Publica. May 19, 2023.

The unintended clinical consequences of abortion restrictions are beginning to emerge. This article shares how one woman faced personal health risks due to clinician concerns stemming from barriers to abortion care and how the Emergency Medical Treatment & Labor Act (EMTALA) may be employed to minimize care limitations in emergent pregnancy-related situations.
Hyvämäki P, Sneck S, Meriläinen M, et al. Int J Med Inform. 2023;174:105045.
Insufficient or incorrect transfer of patient information, whether caused by human or organizational factors, can result in adverse events during transitions of care. This study used four years of incident reports to identify the types, causes, and consequences of health information exchange- (HIE) related patient safety incidents in emergency care, (ED) emergency medical services (EMS), or home care. The two main kinds of HIE-related incidents were (1) inadequate documentation and inadequate use of information (e.g., deficiencies in content), and (2) causes related to the health professional or organization; consequences were adverse events or additional actions to prevent, avoid, and correct adverse events.
Weiss M, Morrison EW, Szyld D. Front Psychol. 2023;14:1129359.
Psychological safety and willingness to speak up about safety concerns are cornerstone to safety culture. Using four clinical vignettes that described the same case in the Emergency Department but differed with respect to whether a nurse spoke up with treatment-related concerns or remained silent, researchers examined healthcare team members’ perspectives of psychological safety and discussed the importance of organizational and team leadership that encourages and supports speaking up behaviors.
Seeburger EF, Gonzales R, South EC, et al. JAMA Netw Open. 2023;6:e239057.
Verbal or physical violence towards healthcare workers can result in harm of both staff and patients. Based on semi-structured interviews with 25 registered nurses working in the emergency department (ED) at one large academic health system, the authors explored nursing perspectives on how EHR-based behavioral flags – used to identify incidents of workplace violence – can promote clinician safety. Participants identified benefits of the flags as well as concerns (e.g., introduction of bias, potential damage to the patient-clinician relationship), highlighted necessary system improvements, and how related challenges in the ED (e.g., unmet mental health needs of patients, COVID-19-related burnout) can contribute to workplace violence.
Comolli L, Korda A, Zamaro E, et al. BMJ Open. 2023;13:e064057.
Patients presenting to the emergency department (ED) with a chief complaint of dizziness require prompt assessment to rule in or out a serious diagnosis such as stroke. A retrospective chart review was performed on more than 1,500 adult patients presenting to the ED with dizziness to estimate vestibular syndrome classifications (i.e., acute, episodic, chronic) and rates of misdiagnosis. Approximately 20% of patients were diagnosed with acute vestibular syndrome (e.g., stroke) and 10% had an unclear vestibular syndrome at time of ED discharge. Of those with follow-up exams, nearly one-third received a different diagnosis, but only 3.2% received a different vestibular classification.

ACS TQIP Mortality Reporting System Writing Group. J Trauma Acute Care Surg. 2023.

Anonymous case reporting provides opportunities to examine unexpected patient harm instances to pinpoint process changes and enhance learning. This case series shares analysis of adverse events submitted to a trauma center-focused reporting program as tools for improvement. The cases are freely available.
Carpenter C, Jotte R, Griffey RT, et al. Mo Med. 2023;120:114-120.
AHRQ's 2022 report Diagnostic Errors in the Emergency Department: A Systematic Review, which reported an estimated 7.4 million patients receive a misdiagnosis in the emergency department every year, garnered public, practitioner, and researcher attention. In this peer-reviewed commentary, the authors critique several components of the report. They also support AHRQ's recommended next steps, and further call for additional public and private funding opportunities to continue improving diagnostic accuracy in the emergency department.
WebM&M Case April 26, 2023

This case involves a procedural sedation error in a 3-year-old patient who presented to the Emergency Department with a left posterior hip dislocation. The commentary summarizes the indications and risks of procedural sedation in non-surgical settings and highlights the value of implementing system-wide safety protocols and practices to prevent medication administration errors during high-risk procedures.

Vaughan CP, Burningham Z, Kelleher JL, et al. Acad Emerg Med. 2023;30 :340-348 .
The Enhancing Quality of Prescribing Practices for Older Adults in the Emergency Department (EQUIIPPED) program is a multicomponent intervention intended to reduce potentially inappropriate medication (PIM) prescribing among older adults who are discharged from the emergency department (ED). This cluster-randomized trial set at eight Veterans Health Administration (VA) EDs compared the impact of two approaches to the audit and feedback component of the intervention – active provider feedback using academic detailing (i.e., educational outreach visits to improve clinical decision making) versus passive provider feedback using dashboard based on the Beers criteria. Researchers found that academic detailing significantly improved PIM prescribing compared to sites using the dashboard, but noted that dashboard-based audit and feedback may be a reasonable strategy EDs with limited resources.
Herasevich S, Soleimani J, Huang C, et al. BMJ Qual Saf. 2023;Epub Mar 27.
Vulnerable populations, such as those with limited English proficiency, minoritized race or ethnicity, migrant populations, or patients qualifying for public insurance, may be at higher risk for adverse health events. In this review, researchers sought to identify frequency and causes of diagnostic error of vulnerable populations presenting to the emergency department with cardiovascular or cerebrovascular/neurological symptoms. Black patients presenting with cardiovascular symptoms had significantly higher odds of diagnostic error. Other demographic factors did not show similar associations, nor did studies of patients with cerebrovascular/neurological symptoms.

Gillispie-Bell V. USA Today. April 14, 2023.

Structural racism and implicit biases can lead to poor quality of care and adverse outcomes among Black women. This article describes the experience of a Black OB/GYN patient whose concerns about abdominal pain during her pregnancy were not thoroughly evaluated; clinicians also missed risk factors placing her at risk of spontaneous preterm birth.

Washington, DC: VA Office of the Inspector General; March 29, 2023. Report no. 21-03680-80.

Care systems for alcohol use disorder (AUD) patients are suboptimal. This report examines the case of a patient with AUD whose emergency care was mismanaged, uncoordinated, and incomplete, contributing to his death two days after discharge. The safety recommendations shared include improving discharge planning, assessment, and consideration of mental health conditions when caring for AUD patients.
Grenon V, Szymonifka J, Adler-Milstein J, et al. J Patient Saf. 2023;19:211-215.
Large malpractice claims databases are increasingly used as a proxy to assess the frequency and severity of diagnostic errors. More than 5,300 closed claims with at least one diagnostic error were analyzed. No singular factor was identified; instead multiple contributing factors were implicated along the diagnostic pathway.
Petts A, Neep M, Thakkalpalli M. Emerg Med Australas. 2023;35:466-473.
Misinterpretation of radiology test results can contribute to diagnostic errors and patient harm. Using a set of 838 pediatric and adult radiographic examinations, this retrospective study found that radiographers’ interpretations can complement emergency clinicians’ interpretations and increase accuracy compared to emergency clinician interpretation alone.
Gjøvikli K, Valeberg BT. J Patient Saf. 2023;19:93-98.
Closed-loop communication prevents confusion and ensures the healthcare team is operating under a shared mental model. In order to investigate closed-loop communication in real-life care (as opposed to simulations), researchers observed 60 interprofessional teams, including 120 anesthesia personnel. The number of callouts, check-backs, and confirmations were analyzed, revealing only 45% of callouts resulted in closed-loop communication.
WebM&M Case March 15, 2023

A 71-year-old man presented to his physician with rectal bleeding and pain, which was attributed to radiation proctitis following therapy for adenocarcinoma of the prostate. He subsequently developed a potentially life-threatening complication of sepsis while awaiting follow up care for a spontaneous rectal perforation. The commentary addresses the importance of early identification and timely intervention in the event of treatment failure and the post-discharge follow-up programs to improve care coordination and communication during transitions of care.

Perspective on Safety March 15, 2023

This piece discusses the evolution of remote patient monitoring, emergence into use with acute conditions, patient safety considerations, and the continued challenges of telehealth implementation.

This piece discusses the evolution of remote patient monitoring, emergence into use with acute conditions, patient safety considerations, and the continued challenges of telehealth implementation.

Dr. Neal Sikka and Dr. Colton Hood are emergency medicine physicians who work in the Innovative Practice & Telemedicine section at George Washington University Hospital (GW). We spoke with them about their experience implementing remote patient monitoring (RPM) programs, GW’s Maritime Medical Access program, and patient safety considerations in the remote environment.

Griffey RT, Schneider RM, Todorov AA. J Patient Saf. 2023;19:59-66.
Near-miss incidents present useful learning opportunities but frequently go unreported. This study used a computerized trigger tool to identify near-miss incidents in the emergency department (ED). Results show approximately 23% of ED visits during the 13-month study period included a near-miss incident. This analysis suggests computerized trigger tools can be useful to identify near misses that otherwise go unreported.