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 1754 Results

National Quality Forum. 2023 Annual Conference.

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National Quality Forum. Omni Shoreham Hotel, Washington DC, February 20-22, 2023.

This hybrid annual conference will focus motivating innovation through effective measurement in health care. The content will be directed toward a multidisciplinary audience to support healthcare improvement in all communities in areas such as maternal outcomes and equity. The session will feature a presentation of the John Eisenberg award winners and Atul Gawande as a key note speaker.

Self-reported gaps in care coordination and preventable adverse outcomes among older adults receiving home health care.

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Sterling MR, Lau J, Rajan M, et al. J Am Geriatr Soc. 2022;Epub Dec 5.

Home healthcare is common among older adults, who are often vulnerable to patient safety events due to factors such as medical complexity. This cross-sectional study of 4,296 Medicare patients examined the relationship between receipt of home healthcare services, perceived gaps in care coordination, and preventable adverse outcomes. The researchers found that home healthcare was not associated with self-reported gaps in care coordination, but was associated with increases in self-reported preventable drug-drug interactions (but not ED visits or hospital admissions).

Redesigning Event Review with RCA2

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Institute for Healthcare Improvement. Mar 14 - May 16, 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.

Accuracy of spinal anesthesia drug concentrations in mixtures prepared by anesthetists.

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Heesen M, Steuer C, Wiedemeier P, et al. J Patient Saf. 2022;18:e1226-e1230.

Anesthesia medications prepared in the operating room are vulnerable to errors at all stages of medication administration, including preparation and dilution. In this study, anesthesiologists were asked to prepare the mixture of three drugs used for spinal anesthesia for cesarean section. Results show deviation from the expected concentration and variability between providers. The authors recommend all medications be prepared in the hospital pharmacy or purchased pre-mixed from the manufacturer to prevent these errors.

Weight and size descriptors for drug dosing: too many options and too many errors.

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Erstad BL, Romero AV, Barletta JF. Am J Health Syst Pharm. 2022;Epub Oct 4.

Weight-based dosing is vulnerable to error due to inaccurate estimation of body weight, use of metric vs. non-metric units, or patients being underweight or overweight. This commentary suggests strategies for reducing weight- and size-based dosing errors including reduction in reliance on estimated body weight, standardizing descriptor (e.g., body mass index), limiting options in the electronic health record (EHR), and integrating complex calculations into the EHR.

AHRQ Safety Program for Telemedicine.

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Agency for Healthcare Research and Quality.

Telemedicine efforts harbor both risk and reward to patients and providers. The AHRQ Safety Program for Telemedicine is a national effort to develop and implement a bundle of evidence-based interventions designed to improve telemedicine care in two settings—the cancer diagnostic process and antibiotic use. To test the bundle of interventions, the program will involve two cohorts of healthcare professionals who utilize telemedicine as a care delivery model. It is an 18-month program, beginning in June 2023, that seeks to improve the cancer diagnostic process for patients who receive some or all of their care through telemedicine. Recruitment webinars start in late January and run through early May 2023; the antibiotic use cohort will begin recruitment in December 2023.

International Society for Quality in Health Care Conference.

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International Society for Quality in Health Care, Korean Society for Quality in Health Care, Health Insurance Review and Assessment Service, and the Korea Institute for Healthcare Accreditation, COEX Convention and Exhibition Center, Seoul, Republic of Korea, August 27-30, 2023.

This conference will explore the theme of “'Technology, Culture, and Coproduction: Looking to the Horizon of Quality and Safety” and will provide sessions on patient safety topics such as learning from mistakes, human factors and Safety II. The call for papers closes January 26, 2023.

Diagnostic Errors in the Emergency Department: a Systematic Review.

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Newman-Toker DE, Peterson SM, Badihian S, et al. Rockville, MD: Agency for Healthcare Research and Quality; December 2022. AHRQ Publication No. 22(23)-EHC043.

Although diagnostic accuracy in the emergency department (ED) is high, diagnostic errors still occur. This evidence review estimated that 1 in 18 ED patients receive an incorrect diagnosis, which translates to 7.4 million patients misdiagnosed every year (or 5.7% of all ED visits annually). Five conditions were found to be most vulnerable to misdiagnosis: stroke, heart attack, aortic aneurysm/ dissection, spinal cord injury and blood clots. The evidence review identified variation in diagnostic error rates across demographic groups; female sex and non-White race were often associated with increased risk for diagnostic errors. Serious misdiagnosis-related harms were often associated with clinician bedside judgement and other cognitive failures.

“I’m concerned”: a multi-site assessment of emergency medicine resident speaking up behaviors.

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Feldman N, Volz N, Snow T, et al. J Patient Saf Risk Manag. 2022;27:229-233.

Research with medical and surgical residents has shown they are frequently reluctant to speak up about safety and unprofessional behavior they observe. This study asked emergency medicine residents about their speaking up behaviors. Using the Speaking Up Climate (SUC)-Safe and SUC-Prof surveys, residents reported generally neutral responses to speaking up, more favorable than their medical and surgical counterparts. In line with other studies, residents were more likely to speak up about patient safety than about unprofessional behaviors.

Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation.

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WebM&M Case December 14, 2022

A 62-year-old Spanish-speaking woman presented to the pre-anesthesia area for elective removal of a left thigh lipoma. Expecting a relatively simple outpatient operation, the anesthesiologist opted not to use a Spanish language translator and performed a quick pre-anesthesia evaluation, obtaining her history from the medical record. Unknown to the anesthesiologist, the patient was trying to communicate to him that she had undergone jaw replacement surgery and that her mouth opening was therefore anatomically limited.

A framework for assessing reasoning about controversial end-of-life clinical decisions.

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WebM&M Case December 14, 2022

A 65-year-old man with metastatic liver disease presented to the hospital with worsening abdominal pain after a partial hepatectomy and development of a large ventral hernia. Imaging studies revealed perforated diverticulitis. A goals-of-care discussion was led by the palliative care service; the patient and his designated decision-makers chose to pursue non-operative management of diverticulitis.

Fast does not imply flawed: analyzing emergency physician productivity and medical errors.

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Hoot NR, Barbosa TJ, Chan HK, et al. J Am Coll Emerg Physicians Open. 2022;3:e12849.

Previous research has suggested that increases in physician workloads can threaten patient safety. This retrospective study found that medical errors are higher among emergency medicine physicians with lower productivity, as measured by the number of patients seen per hour.

Rise to Health Coalition.

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Boston, MA; Institute for Healthcare Improvement: December 2022.

Systemic efforts to improve health equity support patient safety. This announcement highlights an initiative for collective work to address four areas of effort to reduce inequity in health care: access, workforce, social and structural drivers, and quality and safety.

Preventing errors when preparing and administering medications via enteral feeding tubes.

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ISMP Medication Safety Alert! Acute care edition. November 17, 2022;27(23).

Enteral feeding tube medication delivery presents safety challenges that can cause harm. This article highlights problems with feed tube medication administration. It shares improvement recommendations that include best practice adherence, standardization, monitoring, and patient engagement.

Patient safety culture in assisted living: staff perceptions and association with state regulations.

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Temkin-Greener H, Mao Y, McGarry B, et al. J Am Med Dir Assoc. 2022;23:1997-2002.e3.

Long-term care facilities can struggle with establishing a safety culture. Researchers in this study adapted the AHRQ Surveys on Patient Safety Culture™ (SOPS®) Nursing Home Survey to assess patient safety culture in assisted living facilities. Findings show that direct care workers had significantly worse perceptions of patient safety culture (including nonpunitive responses to mistakes, management support for resident safety, and teamwork) compared to administrators. A PSNet perspective discusses how to change safety culture.

Using consumer engagement strategies to improve healthcare safety for young people: an exploration of the relevance and suitability of current approaches.

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Newman B, Joseph K, McDonald FEJ, et al. Health Expect. 2022;25:3215-3224.

Patient engagement focuses on involving patients in detecting adverse events, empowering patients to speak up, and emphasizing the patient’s role in a culture of safety. Young people ages 16-25 with experiences in cancer care, and staff who support young people with cancer were asked about their experiences with three types of patient engagement strategies. Four themes for engaging young people emerged, including empowerment, transparency, participatory culture, and flexibility. Across all these was a fifth theme of transition from youth to adult care.

Interprofessional team collaboration and work environment health in 68 US intensive care units.

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Pun BT, Jun J, Tan A, et al. Am J Crit Care. 2022;31:443-451.

Team collaboration is an essential part of ensuring patient safety in acute care settings. This survey of care team members (including nurses, physicians, pharmacists, respiratory therapists, and rehabilitation therapists) assessed teamwork and collaboration across 68 intensive care units (ICUs). Teamwork and work environment were rated favorably but care coordination and meaningful recognition were rated least favorably.

Finding & Creating Joy in Work.

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Institute for Healthcare Improvement. March 8 - May 16, 2023.

Burnout among health care workers negatively affects system improvement. This webinar series will highlight strategies to establish a healthy work environment that strengthens teamwork, staff engagement, and resilience. Instructors include Dr. Donald Berwick and Derek Feeley.

Unintended consequences of patient online access to health records: a qualitative study in UK primary care.

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Turner A, Morris R, McDonagh L, et al. Br J Gen Pract. 2022;73:e67-e74.

Patient access to electronic health records can improve engagement in care. This qualitative study involving patients and staff at general practices in the United Kingdom highlighted unintended consequences of online access to health records, including challenges with patient health literacy, decreased quality of documentation, and increases in staff workload.

Patient voices in hospital safety during the COVID-19 pandemic.

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Groves PS, Bunch JL, Hanrahan KM, et al. Clin Nurs Res. 2023;32:105-114.

Patients can provide a unique perspective on safety concerns but may hesitate to speak up. This study was conducted with 19 recently discharged patients or their family members to understand safety or quality concerns they experienced during their stay and whether they voiced the concern to their care team. The paper presents types of concerns and, if parents did not have concerns, what made them feel safe, as well as barriers and facilitators to speaking up.

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