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 119 Results

I like what you are saying, but only if I feel safe: psychological safety moderates the relationship between voice and perceived contribution to healthcare team effectiveness.

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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.

Non-accidental Injuries in Infants Attending the Emergency Department.

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

Misattribution of child maltreatment injuries can be a serious misdiagnosis affecting families and patients. This report analyzes ten safety incident reports from across the British National Health Service to explore how non-accidental injury was missed. Themes identified as contributing to the problems include lack of information sharing, inconsistent guidance, and emergency department care demands.

Qualitative perspectives of emergency nurses on electronic health record behavioral flags to promote workplace safety.

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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.

Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act of 2023.

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118th Cong (2023-2024).

Nurse staffing and patient care outcomes are linked, yet variation exists in nursing coverage throughout the United States. This submitted bill aims to legislate a national minimum nurse-to-patient staffing ratio as a strategy to enhance safety and quality improvement.

The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department.

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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.

Reducing diagnostic errors in the emergency department at the time of patient treatment.

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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.

Near-miss events detected using the emergency department trigger tool.

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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.

Crisis in the Lakeshore Hospital ER.

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Derfel A. Montreal Gazette. February 24- March 1, 2023

Emergency room failures are often rooted in system weaknesses. This series examines six patient deaths associated with emergency care that, while concerns were raised by nursing staff, have not been explored to initiate improvements at the facility. Factors contributing to the deaths discussed include nurse shortages, inconsistent oversight, and poor training.

Misdiagnosis in the emergency department: time for a system solution.

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Edlow JA, Pronovost PJ. JAMA. 2023;329:631-632.

Medical errors should be examined in the context of system failure to generate lasting opportunities for learning and improvement. This commentary discusses the AHRQ 2022 report entitled Diagnostic Errors in the Emergency Department: a Systematic Review and suggests a focus on care delivery processes over individuals, definitions, error rate review, and system design as noteworthy approaches to error reduction.

"Do no harm": promoting anti-racist policing in pediatric emergency departments through 20 practice change considerations.

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Wells JM, Walker VP. Health Promot Pract. 2023:152483992211451.

Addressing racism in healthcare is a patient safety priority. This article discusses how an active presence by hospital threat management systems (e.g., hospital-employed security, local law enforcement personnel) in pediatric emergency departments (EDs) can help ensure patient safety but also contributes to unsafe care due to racial stereotypes and threat perception among minority patients and caregivers. The authors outline patient-centered strategies at the individual-, intra-organizational-, and extra-organizational levels for responding to disruptive and violent events.

Patient and hospital characteristics associated with delayed diagnosis of appendicitis.

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Reyes AM, Royan R, Feinglass J, et al. JAMA Surg. 2023;158:e227055.

Delays in diagnosis and treatment can lead to poor outcomes. In this population-based retrospective longitudinal study using inpatient and emergency department discharge data from four states, researchers found that non-Hispanic Black patients were at higher risk for delayed diagnosis of appendicitis compared to White patients. This increased risk for delayed diagnosis translated into higher risks for postoperative 30-day readmission rates. The researchers found that this risk was mitigated when Black patients received care at hospitals serving a more diverse patient population.

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Huff NR, Liu G, Chimowitz H, et al. Int J Nurs Stud Adv. 2022;5:100111.

Negative emotions can adversely impact perception of both patient safety and personal risks. In this study, emergency nurses were surveyed about their emotions (e.g., afraid, calm), emotional suppression and reappraisal behaviors, and perceived risk of personal and patient safety during the COVID-19 pandemic. Nurses reported feeling both positive and negative emotions, but only negative emotions were significantly associated with greater perception of risk.

ER doctors misdiagnose patients with unusual symptoms.

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Abelson R. New York Times. December 15, 2022.

Emergency department safety is challenged by factors such as production pressure, burnout, and overcrowding. This news article provides context for the 2022 AHRQ report Diagnostic Errors in the Emergency Department: A Systematic Review from the Johns Hopkins Medicine Evidence-based Practice Center (EPC) which synthesized the number of patients harmed while seeking emergency care.

Interprofessional clinical event debriefing-does it make a difference? Attitudes of emergency department care providers to INFO clinical event debriefings.

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Rose SC, Ashari NA, Davies JM, et al. CJEM. 2022;24:695-701.

Debriefing is used to enhance individual and team communication and to facilitate real-time learning opportunities after a critical event. This study evaluated a charge nurse-facilitated clinical debriefing program used in Emergency Departments (EDs) in Alberta, Canada. Qualitative analyses identified several themes underscoring the impact of the debriefing program – the impacts on clinical practice and patient care, impacts on psychological safety and teamwork, stress management, and the emotional acknowledgement after critical events – and barriers to debriefing.

Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions

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Perspective on Safety November 16, 2022

Human factors engineering or ergonomics (HFE) is a scientific discipline broadly focused on interactions among humans and other elements of a system.

In Conversation with Dr. Michelle Schreiber on Measuring Patient Safety

We spoke to Dr. Michelle Schreiber about measuring patient safety, the CMS National Quality Strategy, and the future of measurement. Michelle Schreiber, MD, is the Deputy Director of the Center for Clinical Standards and Quality and the Director of the Quality Measurement and Value-Based Incentives Group at the Centers for Medicare & Medicaid Services.

Catching those who fall through the cracks: integrating a follow-up process for emergency department patients with incidental radiologic findings.

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Patient Safety Innovation November 16, 2022

Appropriate follow-up of incidental abnormal radiological findings is an ongoing patient safety challenge. Inadequate follow-up can contribute to missed or delayed diagnosis, potentially resulting in poorer patient outcomes. This study describes implementation of an electronic health record-based referral system for patients with incidental radiologic finding in the emergency room.

Improving discharge safety in a pediatric emergency department.

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Paydar-Darian N, Stack AM, Volpe D, et al. Pediatrics. 2022;150:e2021054307.

Errors during the discharge process can lead to return visits and adverse health outcomes. This article describes the implementation of a new standardized discharge process (including a new checklist, provider huddle, and scripted caregiver education) at one children’s hospital. Over a 19-month period, implementation of the revised discharge process led to the elimination of preventable, discharge-related serious safety events and did not result in increased length-of-stay or return visits.

Optimizing Pediatric Patient Safety in the Emergency Care Setting.

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Joseph MM, Mahajan P, Snow SK, et al. Pediatrics. 2022;150:e2022059673.

Children with emergent care needs are often cared for in complex situations that can diminish safety. This joint policy statement updates preceding recommendations to enhance the safety of care to children presenting at the emergency department. It expands on the application of topics within a high-reliability framework focusing on leadership, managerial factors, and organizational factors that support safety culture and workforce empowerment to support safe emergency care for children.

Barcode medication administration software technology use in the emergency department and medication error rates.

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Gauthier-Wetzel HE. Comput Inform Nurs. 2022;40:382-388.

Barcode medication administration (BCMA) has been promoted as an effective method for reducing medication administration errors. In the emergency department of one Veterans Affairs Medical Center, medication error rates decreased by nearly 11% following introduction of BCMA technology. However, unsafe workarounds were also identified, which may limit the overall safety of BCMA.

Emergency department adverse events detected using the emergency department trigger tool.

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Griffey RT, Schneider RM, Todorov AA. Ann Emerg Med. 2022;80:528-538.

Trigger tools are a novel method of detecting adverse events. This article describes the location, severity, omission/commission, and type of adverse events retrospectively detected using the computerized Emergency Department Trigger Tool (EDTT). Understanding the characteristics of prior adverse events can guide future quality and safety improvement efforts.

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