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 2274 Results

Voices from the Frontlines of Health Care Safety.

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Boston, MA; Betsy Lehman Center; April 2023.

Well-told stories can motivate change. This video translates the experience of Massachusetts patients and family members with medical error for a broad audience. Clinicians also participate and share perspectives on problems in care systems that contribute to patient harm.

Redesigning Event Review with RCA2

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Institute for Healthcare Improvement. September 13 - November 7, 2023.

Root cause analysis (RCA) is a widely recognized retrospective strategy for learning from failure that is challenging to implement. This series of webinars will feature an innovative approach to RCA that expands on the concept to facilitate its use in incident investigations. Instructors for the series will include Dr. Terry Fairbanks and Dr. Tejal K. Gandhi.

Implementing an electronic root cause analysis reporting system to decrease hospital-acquired pressure injuries.

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Armstrong AA. J Healthc Qual. 2023;45:125-132.

Healthcare-acquired pressure injuries (HAPI) can result in increased lengths of stay, hospital readmissions, and lower quality of life. This article describes the experience of one hospital which, after it discovered it had higher-than-average HAPI rates, conducted a root cause analysis to determine contributing factors and identify potential solutions. Dedicated nursing staff were hired and trained, and an electronic health record form was developed to document and track HAPI. A root cause analysis was completed for each HAPI to identify trends and implement improvements.

Analysis of reported suicide safety events among veterans who received treatment through Department of Veterans Affairs-contracted community care.

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Riblet NB, Soncrant C, Mills PD, et al. Mil Med. 2023;Epub Mar 31.

Patient suicide is a sentinel event, and suicide among veterans has gained attention. In this retrospective analysis of suicide-related events reported to the Veterans Health Administration (VHA) National Center for Patient Safety between January 2018 and June 2022, researchers found that deficiencies in mental health treatment, communication challenges, and unsafe environments were the most common contributors to suicide-related events.

Using morbidity and mortality conferences to drive quality improvement and reduce errors.

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Lai B, Horn J, Wilkinson J, et al. Fam Pract Manag. 2023;30(2):13-17.

Morbidity and mortality (M&M) conferences are an established mechanism used to facilitate discussion of errors to generate learning. This peer-reviewed article discusses how one organization implemented an M&M program. The authors share steps taken to support success which include case selection, nonjudgmental culture, and subject matter expert involvement.

Towards a unified model of accident causation: refining and validating the systems thinking safety tenets.

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Salmon PM, Hulme A, Walker GH, et al. Ergonomics. 2023;66:644-657.

Systems thinking concepts are used by healthcare organizations to encourage learning from failures and identifying solutions to complex patient safety problems. This article outlines a refined and validated set of systems thinking tenets and discusses how they can be used to proactively identify threats to patient safety.

Curated Libraries

Implementation of Patient Safety Projects Curated Library

May 4, 2023

The implementation of effective patient safety initiatives is challenging due to the complexity of the health care environment. This curated library shares resources summarizing overarching ideas and strategies that can aid in successful program execution, establishment, and sustainability.

Improving Diagnostic Safety and Quality

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Perspective on Safety April 26, 2023

Throughout 2022, AHRQ PSNet has shared research that elucidates the complex nature of misdiagnosis and diagnostic safety. This Year in Review explores recent work in diagnostic safety and ways that greater safety may be promoted using tools developed to improve diagnostic practices.

Adopting high reliability organization principles to lead a large scale clinical transformation.

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Pozzobon LD, Lam J, Chimonides E, et al. Healthc Manage Forum. 2023;Epub Apr 6.

High-reliability organizations are able to achieve safety despite organizational changes or other hazardous conditions. This article describes the implementation of a new electronic health record (EHR) system at one academic health system in Canada and provides examples of how high-reliability principles informed activities to prevent patient harm during this organizational change.

Factors associated with diagnostic error: an analysis of closed medical malpractice claims.

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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.

Using the Generic Analysis Method to analyze sentinel event reports across hospitals: a retrospective cross-sectional study.

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Baartmans MC, van Schoten SM, Smit BJ, et al. J Patient Saf. 2023;19:158-165.

Sentinel events are adverse events that result in death or severe patient harm and require a full organizational investigation to identify root causes and make recommendations to prevent recurrence. This study pooled sentinel event reports from 28 Dutch hospitals to identify common system-level contributing factors. Aggregation of system-level factors may provide more urgency in implementing recommendations than a single case at one organization.

Hospital ‘black boxes’ put surgical practices under the microscope.

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Sadick B. Wall Street Journal. March 19, 2023.

Safety information systems that track action in real time can reveal a trove of data about how teams and procedures progress. This news article describes the use of a black-box system in the operating room. Its use by hospitals in the United States is described to illustrate the value of black box data to inform learning and improvement strategies.

Evaluating patient identification practices during intrahospital transfers: a human factors approach.

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Suclupe S, Kitchin J, Sivalingam R, et al. J Patient Saf. 2023;19:117-127.

Patient identification mistakes can have serious consequences. Using the Systems Engineering for Patient Safety (SEIPS) framework, this qualitative study explored systems factors contributing to patient identification errors during intrahospital transfers. The authors found that patient identification was not completed according to hospital policy during any of the 60 observed patient transfer handoffs. Miscommunication and lack of key patient information were common factors contributing to identification errors.

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

Curated Libraries

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.

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.

Using Failure Mode, Effect and Criticality Analysis to improve safety in the cancer treatment prescription and administration process.

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Buja A, De Luca G, Ottolitri K, et al. J Pharm Policy Pract. 2023;16:9.

Failure Mode, Effect and Criticality Analysis (FMECA) is a prospective method for identifying and preventing potential error risks. Using FMECA, public health medical residents calculated a Risk Priority Number (RPN), or criticality, for each possible failure mode in cancer treatment prescription and administration. Each phase of the cancer treatment process had at least one critical step identified, and actions were developed to reduce the likelihood of the error occurring and/or to increase the likelihood of the error being detected.

Risk assessment of the acute stroke diagnostic process using failure modes, effects, and criticality analysis.

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Liberman AL, Holl JL, Romo E, et al. Acad Emerg Med. 2022;30:187-195.

A missed or delayed diagnosis of stroke places patients at risk of permanent disability or death. This article describes how interdisciplinary teams used a failure modes, effects, and criticality analysis (FMECA) to create an acute stroke diagnostic process map, identify failures, and highlight existing safeguards. The FMECA process identified several steps in the diagnostic process as the most critical failures to address, including failure to screen patients for stroke soon after presentation to the Emergency Department (ED), failure to obtain an accurate history, and failure to consider a stroke diagnosis during triage.

Race differences in a malpractice event database in a large healthcare system.

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Thomas AD, Pandit C, Krevat S. J Patient Saf. 2023;19:67-70.

Previous research has identified disparities in adverse events and patient safety risks for Black patients compared to White patients. In this study, researchers used a large healthcare system’s malpractice database to examine racial differences in malpractice lawsuits. Although there were no significant race differences in lawsuits, findings suggest that employees are more likely to identify potential malpractice events for White patients compared to Black patients.

Is anybody 'Learning' from deaths? Sequential content and reflexive thematic analysis of national statutory reporting within the NHS in England 2017-2020.

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Brummell Z, Braun D, Hussein Z, et al. BMJ Open Qual. 2023;12:e002093.

In 2017, England’s National Health Service (NHS) implemented the Learning from Deaths program which requires NHS Secondary Care Trusts (NSCT) to report, investigate, and learn from potentially preventable deaths. This study focuses on what NCSTs learned during the first three years of the program, the actions taken in response and their impact, and engagement with Learning from Deaths. Trusts appear to have varied understanding and use of the term ‘learning’ and not all specified the impact their actions had on patient safety.

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