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 2305 Results

Perspectives on perioperative team-based morbidity and mortality conferences: a mixed-methods study.

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Samost-Williams A, Rosen R, Cummins E, et al. Jt Comm J Qual Patient Saf. 2023;Epub Oct 15.

Team-based morbidity and mortality conferences (TBMMs) involve multidisciplinary or interdisciplinary teams in discussions about complex cases and medical errors. This survey of 1,466 perioperative health care professionals found positive perceptions of TBMMs and traditional Morbidity and Mortality Conferences, but identified several barriers to effective implementation of TBMMs, including unsupportive leadership and fear of professional consequences.

Team experiences of the root cause analysis process after a sentinel event: a qualitative case study.

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Liepelt S, Sundal H, Kirchhoff R. BMC Health Serv Res. 2023;23:1224.

Root cause analysis (RCA) is a frequently used, and sometimes mandatory, method to investigate sentinel events. In this study, members of an RCA committee were interviewed before and after an RCA investigation to elicit their experiences and assess compliance with the Norwegian RCA process. Organizational factors and team composition presented challenges, particularly the inclusion of staff closely involved with the incident under investigation.

Deficiencies in Quality Management Processes and Delays in the Communication of Test Results and Follow-Up Care at the Phoenix VA Health Care System in Arizona.

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Washington DC; VA Office of the Inspector General; October 31, 2023; Report no. 22-03599-07.

Disclosure failures detract from learning, appropriate incident examination, and safe care delivery. This report examined factors contributing to poor disclosure practices associated with the care of three patients. Lack of report submission, uninitiated root cause analysis, and inadequate documentation were process weaknesses highlighted by the review.

Redesigning Event Review with RCA2.

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Institute for Healthcare Improvement. March 13 - April 23, 2024.

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.

Defining a high-quality and effective morbidity and mortality conference: a systematic review.

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Beaulieu-Jones BR, Wilson S, Howard DS, et al. JAMA Surg. 2023;Epub Oct 18.

Morbidity and Mortality Conferences (MMC) have a long history in medical education and error analysis. This review summarizes MMC best practices to optimize format and design to advance trainee education and format. Four overarching themes emerged, including formal preparation in advance of the MMC, a balance of presentation and discussion, formal channels for quality improvement and education, and an emphasis on safety culture.

Hospital Harm Project.

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Canadian Institute for Health Information, Health Excellence Canada.

Reducing preventable harm associated with health care is a worldwide goal. This Canadian initiative developed a measure to track unintended harm in acute care hospitals, a toolkit to accompany reduction efforts, and reports that assess the results of improvement efforts and provide data analysis.

Exploring the "Black Box" of recommendation generation in local health care incident investigations: a scoping review.

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Lea W, Lawton R, Vincent CA, et al. J Patient Saf. 2023;19:553-563.

Organizational incident reporting allows for investigation of contributing factors and formation of improvement recommendations, but some recommendations are weak (e.g., staff training) and do not result in system change. This review found 4,579 recommendations from 11 studies, with less than 7% classified as "strong". There was little explanation for how the recommendations were generated or if they resulted in improvements in safety or quality of care. The authors contend additional research into how recommendations are generated and if they result in sustained improvement is needed.

Adverse drug events caused by three high-risk drug-drug interactions in patients admitted to intensive care units: a multicentre retrospective observational study.

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Klopotowska JE, Leopold J‐H, Bakker T, et al. Br J Clin Pharmacol. 2023;Epub Aug 11.

Identifying and preventing drug-drug interactions (DDI) is critical to patient safety, but the usual method of detecting DDI and other errors - manual chart review - is resource intensive. This study describes the use of an e-trigger to pre-select charts for review that are more likely to include one of three DDIs, thus reducing the overall number of charts needing review. Two of the DDI e-triggers had high positive predictive values (0.76 and 0.57), demonstrating that e-triggers can be a useful method to pre-selecting charts for manual review.

Developing surgical and anesthesia resident patient safety competencies through systems-based event analysis. Guide to curricular development and evaluation of longer-term resident perceptions.

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Bagian JP, Paull DE, DeRosier JM. Surg Open Sci. 2023;16:33-36.

The Accreditation Council for Graduate Medical Education (ACGME) requires post-graduate education to include patient safety curriculum. This article describes the development and evaluation of a curriculum for residents on patient safety investigations using the Root Cause Analysis and Action (RCA2) model. Residents were surveyed at least one year after completion of the training. Sixty-three percent of respondents agreed or strongly agreed residents should be provided with the RCA2 training and nearly half reported having participated on an RCA team since completing the program.

Healthcare Failure Mode and Effects Analysis.

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ECRI and the Institute for Safe Medication Practices. November 14, 2023, 12:00-5:00 PM (eastern).

Failure mode and effect analysis (FMEA) is a proactive method to identify risks at each step in the process. Attendees of this training will learn how and why healthcare FMEA is performed, and apply their learning to case studies.

Perioperative team-based morbidity and mortality conferences: a systematic review of the literature.

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Samost-Williams A, Rosen R, Hannenberg A, et al. Ann Surg Open. 2023;4:e321.

Morbidity and mortality conferences offer important opportunities for healthcare teams to discuss adverse events, learn from errors, and improve patient safety. This systematic review examined beneficial aspects of perioperative team-based morbidity and mortality (TBMM) conferences. The authors found that TBMM conferences generally led to improvements in patient safety, quality improvement, and educational outcomes and that certain factors (case preparation, standardized presentation format, effective facilitation) increase TBMM benefits.

Implementing patient safety and quality improvement in dermatology.

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Marsch A, Khodosh R, Porter M, et al. J Am Acad Dermatol. 2023;89(4):641-54; 57-67.

Patient safety in dermatology has received increasing attention over the past ten years. Part 1 of this series provides examples of patient safety concerns in dermatology (e.g., medication errors, teledermatology) and how key patient safety concepts such as safety culture and root cause analysis can be applied in dermatology settings. Part 2 of this series applies three quality improvement frameworks (LEAN, Six Sigma, and IHI-QI) can be used to improve the quality and safety of dermatology practice.

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.

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