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 2295 Results

Adverse Health Events in Minnesota: Annual Reports.

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St Paul, MN: Minnesota Department of Health.

The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery. Since 2003, Minnesota hospitals have been required to report such incidents. The 2022 report summarizes information about 572 adverse events that were reported, representing a significant increase in the year covered. Earlier reports prior to the last two years reflect a fairly consistent count of adverse events. The rise documented here is likely due to demands on staffing and care processes associated with COVID-19 and general increases in patient complexity and subsequent length of stay. Pressure ulcers and fall-related injuries were the most common incidents recorded. Reports from previous years are available.

Making a move: using simulation to identify latent safety threats before the care of injured patients in a new physical space.

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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.

A Missed Bowel Perforation –the Importance of Diagnostic Reasoning

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WebM&M Case September 27, 2023

This case describes the failure to identify a brewing abdominal process, which over the span of hours led to fulminant sepsis with rapid clinical deterioration and eventual demise. The patient’s ascitic fluid cultures and autopsy findings confirmed bowel perforation, but this diagnosis was never explicitly considered.

Disclosure of Medical Errors.

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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.

In-situ simulations to detect patient safety threats during in-hospital cardiac arrest.

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Stærk M, Lauridsen KG, Johnsen J, et al. Resusc Plus. 2023;14:100410.

In situ simulation is a valuable tool to identify latent safety threats. In this study, 36 unannounced in situ in-hospital cardiac arrest (IHCA) simulations were conducted across 4 hospitals and identified 30 system errors. Errors were categorized as involving human, organization, hardware, or software errors. These system errors contributed to treatment delays and care omissions.

Annual Speak Up Data Reports.

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Stratford, London; The National Guardian.

Organizational efforts to collect and respond to the concerns of staff and patients are a cornerstone to patient safety improvement despite challenges to implement them. This annual report presents insights drawn from problems staff share with Freedom to Speak Up Guardians in the United Kingdom to capitalize on problems to drive improvement. The 2023 report summarized data collected from over 25,000 cases recorded.

The e-Autopsy/e-Biopsy: A Systematic Chart Review to Increase Safety and Diagnostic Accuracy Innovation

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Patient Safety Innovation August 30, 2023

Addressing diagnostic errors to improve outcomes and patient safety has long been a problem in the US healthcare system.¹ Many methods of reducing diagnostic error focus on individual factors and single cases, instead of focusing on the contribution of system factors or looking at diagnostic errors across a disease or clinical condition. Instead of addressing individual cases, KP sought to improve the disease diagnosis process and systems. The goal was to address the systemic root cause issues in systems that lead to diagnostic errors.

A natural language processing approach to categorise contributing factors from patient safety event reports.

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Tabaie A, Sengupta S, Pruitt ZM, et al. BMJ Health Care Inform. 2023;30(1):e100731.

Analyzing patient safety incident reports is essential to organizational learning, but comes with both a time and financial burden. This study found that natural language processing can be used to process unstructured patient safety event reports and reduce the burden of manually identifying and extracting factors contributing to the event.

The Pursuing Excellence Collaborative: engaging first-year residents and fellows in patient safety event investigations.

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Paull DE, Newton RC, Tess AV, et al. J Patient Saf. 2023;19:484-492.

Previous research suggests that residents may underutilize adverse event reporting tools. This article describes an 18-month clinical learning collaborative among 16 sites intended to increase resident and fellow participation in patient safety event investigations. Researchers found the collaborative increased participation in event investigation and improved the quality of the investigation.

Common contributing factors of diagnostic error: a retrospective analysis of 109 serious adverse event reports from Dutch hospitals.

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Hooftman J, Dijkstra AC, Suurmeijer I, et al. BMJ Qual Saf. 2023;Epub Aug 9.

Diagnostic errors are common and have many contributing factors. This study analyzed more than 100 serious adverse event (SAE) reports in acute care using four investigation methods (e.g., Diagnostic Error Evaluation Research (DEER) taxonomy, Safer Dx Instrument) to identify common contributing factors. Transitions of care were particularly vulnerable to SAE, often due to incomplete communication between departments. Diagnostic errors occurred most often in the testing, assessment, and follow-up phases, with human factors as the most common contributing factor. Using multiple investigative methods supports more targeted interventions in each phase of diagnosis.

A multi-facetted patient safety resource--a qualitative interview study on hospital managers' perception of the nurse-led Rapid Response Team.

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Axelsen MS, Baumgarten M, Egholm CL, et al. J Adv Nurs. 2023;Epub Jun 30.

Rapid response teams (RRT) are activated, typically by nurses, when a patient demonstrates signs of imminent clinical deterioration, in order to prevent death or transfer to the intensive care unit (ICU). This study asks ICU managers about their perceptions of RRT beyond the stated goal of preventing patient deterioration. They describe the RRT as providing valuable education for new nurses and physicians and enhancing cohesion between the ICU and other wards. However, nurse managers stated they wanted more data and feedback from executive leadership.

Physician engagement in organisational patient safety through the implementation of a Medical Safety Huddle initiative: a qualitative study.

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Rotteau L, Othman D, Dunbar-Yaffe R, et al. BMJ Qual Saf. 2023;Epub Jul 19.

Safety huddles are increasingly used to encourage team communication about safety threats and learning from mistakes. This qualitative study with huddle leaders and participants at five sites found that huddles can enhance engagement in patient safety and identify opportunities for increased support from organizational leadership.

Identifying failure modes in telemedicine: an instructional needs assessment.

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Monkman H, Kuziemsky C, Homco J, et al. Stud Health Technol Inform. 2023;304:39-43.

Implementation challenges can hinder the safety of telehealth. In this study, medical students used Healthcare Failure Modes and Effect Analysis to identify the causes of failures in telehealth and potential prevention strategies. Four categories of failures were identified: technical issues, patient safety, communication, and social and structural determinants.

Experimental evidence for structured information-sharing networks reducing medical errors.

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Centola D, Becker J, Zhang J, et al. Proc Natl Acad Sci U S A. 2023;120:e2108290120.

Collective intelligence posits that the judgment (in this case, diagnostic accuracy) of a group of individuals outperforms the judgment of a single individual. This study sought to determine if real-time information-sharing improved not only group diagnostic accuracy, but also diagnostic accuracy of the individuals within the group. Individual accuracy did improve, suggesting real-time information-sharing between physicians could improve diagnostic decision-making in practice, although additional research is required.

Deficiencies in Emergency Department Care for a Patient Who Died by Suicide at the John Cochran Division of the VA St. Louis Health Care System in Missouri.

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Washington DC: Department of Veterans Affairs, Office of Inspector General; June 29, 2023. Report no. 22-01540-146.

This report analyzed a patient suicide at an emergency department and determined factors in the delay of care that contributed to patient harm. This report shares recommendations to address leadership failures and other deficiencies including poor screening and patient monitoring. Post-event gaps identified include poor root cause analysis, disclosure, and reporting activities.

Investigation of urology intraoperative events leading to root cause analysis at national VA medical centers.

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Peard LM, Teplitsky S, Annabathula A, et al. Can J Urol. 2023;30(2):11467-11472.

Root cause analysis (RCA) is one tool commonly used to identify factors contributing to adverse events. Using RCA data from the Veterans Health Administration (VHA), this study characterized adverse events occurring during urologic procedures. The most common causes of adverse events were improperly functioning equipment (e.g., broken scopes or smoking light cords), wrong site surgeries, and retained surgical items.

Using failure mode and effect analysis to identify potential failures in a psychiatric hospital emergency department.

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Gur-Arieh S, Mendlovic S, Rozenblum R, et al. J Patient Saf. 2023;19:362-368.

Failure mode and effect analysis (FMEA) is a common way to identify error risk. In this study, FMEA was used in a psychiatric hospital emergency department (ED) to identify potential failures. FMEA was completed by two groups, ED staff and non-ED staff, to determine if a multi-professional team could be used for the FMEA process. The groups’ ratings were very similar, indicating a multi-professional team can effectively complete an FMEA.

Root causes and preventability of unintentionally retained foreign objects after surgery: a national expert survey from Switzerland.

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Schwappach DLB, Pfeiffer Y. Patient Saf Surg. 2023;17:15.

Retained surgical items (RSIs) can lead to serious patient harm. Survey findings from 21 clinicians and stakeholders in Switzerland emphasized the importance of addressing production pressures, encouraging a culture of safety and teamwork, and implementation of effective counting procedures to reduce the incidence of retained surgical items.

Understanding the root cause analysis process to increase safety event reporting.

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Dudley KA. AORN J. 2023;117:399-402.

Root cause analysis (RCA) may not be an ideal process, but it still creates opportunities for learning and improvement after a sentinel event. This article posits why perioperative nurses may not report problems to avoid engagement in RCA activities. Increasing nurse awareness of RCA as a multidisciplinary and systems-focused improvement method is a suggested educational tactic to increase nurse RCA participation.

Emotional responses and support needs of healthcare professionals after adverse or traumatic experiences in healthcare-evidence from seminars on peer support.

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Schrøder K, Assing Hvidt E. Int J Environ Res Public Health. 2023;20:5749.

Healthcare providers may experience emotional distress after involvement in an adverse or traumatic event. This qualitative study with 198 healthcare professionals identified common emotions experienced after adverse events as well as the types of support needed after involvement in an adverse event. These findings can contribute to the development and refinement of support programs for healthcare workers after adverse events.

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