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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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.

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.

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.

Fellowships and Mentorships Program.

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Institute for Safe Medication Practices.

These educational programs with the Institute for Safe Medication Practices (ISMP) are for clinicians who wish to expand their practical knowledge of medication error prevention. The application process for the 2023-2024 fellowships will close May 16, 2023.

Positive approaches to safety: learning from what we do well.

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Plunkett A, Plunkett E. Paediatr Anaesth. 2022;32:1223-1229.

Safety-I focuses on identifying factors that contribute to incidents or errors. Safety-II seeks to understand and learn from the many cases where things go right, including ordinary events, and emphasizes adjustments and adaptations to achieve safe outcomes. This commentary describes Safety-II and complementary positive strategies of patient safety, such as exnovation, appreciative inquiry, learning from excellence, and positive deviance.

Combined proactive risk assessment: unifying proactive and reactive risk assessment techniques in health care.

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Bender JA, Kulju S, Soncrant C. Jt Comm J Qual Patient Saf. 2022;48:326-334.

Healthcare organizations use multiple proactive and reactive methods of investigating and preventing adverse events. This study combined proactive and reactive risk assessments into a Combined Proactive Risk Assessment (CPRA) to identify risks not detected by one method on its own. The four steps of CPRA are illustrated using the example of outpatient blood draws in the Veterans Health Administration.

Strategies and Approaches for Investigating Patient Safety Events

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Patient Safety Primer March 30, 2022

This primer provides a broad overview of three widely used tools for investigating and responding to patient safety events and near misses. Tools covered in this primer are incident reporting systems, Root Cause Analysis (RCA), and Failure Modes and Effects Analysis (FMEA). These tools have been used in high-risk industries and occupations such as aviation, manufacturing, nuclear power, and the military and have been adapted for use in enhancing patient safety in healthcare settings over the past two decades.

Reliability, uncertainty and the management of error: new perspectives in the COVID-19 era.

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Schulman PR. J Contingencies Crisis Manage. 2022;30:92-101.

High reliability organizations (HROs) are those that operate in highly complex domains, such as aviation, with no or very few significant errors. This commentary describes the relationship between error and uncertainty in HROs using the increased uncertainties brought on by the COVID-19 pandemic as an example.

Preventing and mitigating radiology system failures: a guide to disaster planning.

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Gibney BT, Roberts JM, D'Ortenzio RM, et al. RadioGraphics. 2021;41:2111-2126.

Hospitals are increasingly creating and updating their emergency disaster response plans. This guide assists hospital executives, quality & safety professionals, and risk managers by assessing potential hazards or failures in radiology departments in the event of disaster. Disaster planning tools, checklists, and other recommendations are described.

A simulation systems testing program using HFMEA methodology can effectively identify and mitigate latent safety threats for a new on-site helipad.

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Holmes J, Chipman M, Barbour T, et al. Jt Comm J Qual Patient Saf. 2022;48:12-24.

Air medical transport carries unique patient safety risks. In this study, researchers used simulation training and healthcare failure mode and effect analysis (HFMEA) to identify latent safety threats related to patient transport via helicopter. This approach identified 31 latent safety threats (18 were deemed critical) related to care coordination, facilities, equipment, and devices.

Using failure mode and effects analysis to increase patient safety in cancer chemotherapy.

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Weber L, Schulze I, Jaehde U. Res Social Adm Pharm. 2022;18:3386-3393.

Chemotherapy administration errors can result in serious patient harm. Using failure mode and effects analysis (FMEA), researchers identified potential failures related to the medication process for intravenous chemotherapy. Common failures included incorrect patient information, non-standardized chemotherapy protocols, and problems related to supportive therapy.

Healthcare failure mode and effect analysis in the chemotherapy preparation process.

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Pueyo-López C, Sánchez-Cuervo M, Vélez-Díaz-Pallarés M, et al. J Oncol Pharm Pract. 2021;27:1588-1595.

Researchers in this study used healthcare failure mode and effect analysis (HFMEA) to identify and reduce errors during chemotherapy preparation. Nine potential failure modes were identified – wrong label, drug, dose, solvent, or volume; non-sterile preparation; incomplete control; improper packaging or labeling, and; break or spill – and the potential causes and effects. Potential approaches to reduce these failure modes include updating the Standard Operating Procedures (SOPs), implementing a bar code system, and using a weight-based control system.

Improving medication reconciliation with comprehensive evaluation at a Veterans Affairs skilled-nursing facility.

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Baughman AW, Triantafylidis LK, O'Neil N, et al. Jt Comm J Qual Patient Saf. 2021;47:646-653.

Medication reconciliation is the process of reviewing a patient’s medication list for discrepancies and safety. Patients in nursing homes are at increased risk for medication discrepancies due to complexity of care and frequent transitions of care. By using Healthcare Failure Mode and Effect Analysis (FMEA), researchers uncovered several factors that contribute to medication discrepancies. Interventions to improve medication safety can be targeted to one or more of the contributing factors.

Reducing failures in daily medical practice: healthcare failure mode and effect analysis combined with computer simulation.

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Leeftink AG, Visser J, de Laat JM, et al. Ergonomics. 2021:1-11.

Failure mode and effect analysis (FMEA) is widely used to identify latent safety hazards. The authors of this study proposed combining healthcare failure mode and effect analysis (HFMEA) with computer simulation (HFMEA-CS) for prospective risk analysis of complex and potentially harmful processes. Use of HFMEA-CS to analyze medication processes during admission and discharge for patients with a rare adrenal tumor led to a reduction in drug delivery and system errors, as well as increased drug adherence.

The fusion of incident learning and failure mode and effects analysis for data-driven patient safety improvements.

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Paradis KC, Naheedy KW, Matuszak MM, et al. Pract Radiat Oncol. 2020;11:e106-e113.

Assessing risk and learning from adverse events are core components of patient safety improvement. The authors propose a method which leverages a radiation oncology incident learning system with a simplified failure mode and effects analysis (FMEA) to analyze safety events and monitor the success of workflow changes to improve patient safety and address high-risk errors.

Healthcare failure mode and effect analysis (HFMEA) as an effective mechanism in preventing infection caused by accompanying caregivers during COVID-19-experience of a city medical center in Taiwan.

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Tiao C-H, Tsai L-C, Chen L-C, et al. Qual Manag Health Care. 2021;30:61-68.

Hospitals have needed to adapt workflow processes to optimize infection control in response to the COVID-19 pandemic. This article describes the use of healthcare failure mode and effects analysis (HFMEA) 4-step model to implement preventive risk assessment and workflow management for high-risk medical procedures during the pandemic and prevention of nosocomial infections.

Algorithmic prediction of failure modes in healthcare.

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Kobo-Greenhut A, Sharlin O, Adler Y, et al. Int J Qual Health Care. 2021;33:mzaa151.

Failure mode and effect analysis (FMEA) is used to asses risk in various heath care processes. This study found that an algorithmic prediction of failure modes in healthcare (APFMH) is more effective in identifying hazards and uses fewer resources (time and human resource investment) than traditional FMEA.

Dispensing Errors.

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Phipps D, Ashour A, Riste L, et al. The Pharmaceutical Journal. 2020;305(7943, 7944). November 10, December 1, 2020.

Dispensing mistakes are a common contributor to preventable adverse events in community pharmacies. Part 1 of this two-part series discusses factors that contribute to dispensing errors and summarizes methods for managing risks stemming from missteps. Part 2 focuses on preventing situations that enable errors and the role pharmacists have in minimizing dispensing errors in daily practice.

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