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 86 Results

Value of improving patient safety: health economic considerations for rapid response systems-a rapid review of the literature and expert round table.

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Subbe CP, Hughes DA, Lewis S, et al. BMJ Open. 2023;13:e065819.

Failure to rescue refers to delayed or missed recognition of clinical deterioration, which can lead to patient complications and death. In this article, the authors used health economics methods to understand the health economic impacts associated with failure to rescue. The authors discuss the economic perspectives of various decision makers and how each group defines value.

APSF Stoelting Conference.

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Anesthesia Patient Safety Foundation. September 6–7, 2023; Red Rock Casino Resort and Spa, Las Vegas, NV.

Anesthesia is a high-risk activity that has achieved safety successes. This hybrid conference will explore topics related to the theme of “Emerging Medical Technologies – A Patient Safety Perspective on Wearables, Big Data and Remote Care.”

Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units

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Perspective on Safety April 26, 2023

This piece discusses surveillance monitoring of patients in low-acuity units of the hospital to prevent failure to rescue events, its difference from high-acuity continuous monitoring, and its potential applications in other settings.

In Conversation with Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring

Drs. Susan McGrath and George Blike discuss surveillance monitoring and its challenges and opportunities.

Frontline nurses' clinical judgment in recognizing, understanding, and responding to patient deterioration: a qualitative study.

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Dresser S, Teel C, Peltzer J. Int J Nurs Stud. 2023;139:104436.

Understanding how nurses use their clinical judgment in activating early warning systems or rapid response teams is important in improving response to deteriorating patients. Interviews with 20 nurses revealed an overarching sense of responsibility to their patients, eight subthemes including experience, making sense of the data, and a culture of teamwork.

Exploration of ward-based nurses' perspectives on their preparedness to recognize clinical deterioration: a scoping review.

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Mikhail J, King L. J Patient Saf. 2023;19:99-109.

Early recognition of warning signs of deterioration is key to activating the rapid response system (RRS) and prevention of serious adverse events. This review sought to understand how preparedness of ward-based nurses supports recognition of early warning signs and activation of RRS. Themes include knowledge of criteria to activate the RRS and deference to organizational hierarchy.

Reducing hospital harm: establishing a command centre to foster situational awareness.

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Patient Safety Innovation March 29, 2023

Situational awareness during complex care events, such as clinical deterioration, medication administration, or the admission process, is an important component of teamwork and high reliability.

Reduction in omission events after implementing a rapid response system: a mortality review in a department of gastrointestinal surgery.

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Olsen SL, Nedrebø BS, Strand K, et al. BMC Health Serv Res. 2023;23:179.

Regular monitoring of vital signs is key to early identification of patient deterioration and provision of rapid response. This hospital in Norway determined inconsistent documentation of vital signs could be a barrier to successful implementation of a rapid response system (RRS). During the decade following introduction and refinement of the RRS, the number of completed vital sign sets increased, as did intensive care consultation, another component of RRS. Overall the RSS was associated with a reduction of in-hospital and 30-day mortality rates.

The role of language barriers on efficacy of rapid response teams.

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Raff L, Moore C, Raff E. Hosp Pract (1995). 2023;51:29-34.

Language barriers can lead to diminished care and threaten patient safety. This retrospective study included patients with rapid response team (RRT) activation and compared disease severity and outcomes for patients whose primary language was Spanish versus English. Findings suggest that language barriers may contribute to delays in RRT activation and delays in care.

Reducing preventable adverse events in obstetrics by improving interprofessional communication skills--results of an intervention study.

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Hüner B, Derksen C, Schmiedhofer M, et al. BMC Pregnancy Childbirth. 2023;23:55.

Safe obstetrical care can be compromised by a variety of controllable risk factors, such as communication between providers. To reduce preventable adverse events, interprofessional obstetric teams (physicians and midwives) in one hospital received training on the importance of team communication. Compared to the year before the training, there was a significantly significant reduction in diagnostic errors and inadequate birth position, but not in other categories.

Maternal and Infant Health Inequality: New Evidence from Linked Administrative Data.

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Kennedy-Moulton K, Miller S, Persson P, et al. Cambridge, MA: National Bureau of Economic Research; 2022. NBER Working Paper No. 30693.

Unequal maternal care access and safety are known problems in communities of color. This report examines the alignment of economic stability with maternal and infant care quality and found parental income secondary to race and ethnicity as a damaging influence on care outcomes.

Investigating the impact of structural racism on black birthing people - associations between racialized economic segregation, incarceration inequality, and severe maternal morbidity.

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Jeffers NK, Berger BO, Marea CX, et al. Soc Sci Med. 2023;317:115622.

Structural racism contributes to high rates of severe maternal morbidity (SMM) experienced by Black patients. This study investigated specific measures of structural racism (incarceration inequality and racialized economic segregation) on Black SMM. In this sample of births from 2008-2011, racialized economic segregation was associated with SMM for black patients; however, incarceration inequality was not.

Eliminating racial and ethnic disparities causing mortality and morbidity in pregnant and postpartum patients.

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Sentinel Event Alert. January 17, 2023:(66):1-5.

Racial and ethnic inequalities are emerging as a primary contributor to harmful maternal care. This guidance examines obstacles to safe care for mothers of color and shares recommendations to reduce disparities such as team-based care and implicit bias training.

Paediatric family activated rapid response interventions; qualitative systematic review.

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Cresham Fox S, Taylor N, Marufu TC, et al. Intensive Crit Care Nurs. 2023;2023:103363.

While many hospitals have rapid response teams (RRT) which can be activated by clinicians, only a few hospitals have also implemented programs which allow patients and families to activate RRT. This review identified 6 articles (5 interventions) with family-activated RRT in pediatric hospitals. The authors of the review conclude that family-activated RRT is a key component to family engagement and enhancing patient safety. Only one intervention was also available in a non-English language, which should be considered in future interventions.

Am I safe? An interpretative phenomenological analysis of vulnerability as experienced by patients with complications following surgery.

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Sutton E, Booth L, Ibrahim M, et al. Qual Health Res. 2022;32:2078-2089.

Patient engagement and encouragement to speak up about their care can promote patient safety. This qualitative study explored patients’ psychosocial experiences after surviving abdominal surgery complications. Findings highlight an overarching theme of vulnerability and how power imbalances between patients and healthcare professionals can influence speaking up behaviors.

Tele-Rapid Response Team (Tele-RRT): the effect of implementing patient safety network system on outcomes of medical patients- a before and after cohort study.

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Balshi AN, Al-Odat MA, Alharthy AM, et al. PLoS ONE. 2022;17:e0277992.

Many hospitals have implemented rapid response teams (RRT) that are activated when a patient starts exhibiting prespecified criteria to prevent adverse outcomes. This before and after study compared nurse-activated RRT and automated activation. Non-invasive bedside sensors monitored patients’ vital signs and automatically sent alerts to the RRT based on prespecified clinical signs. Compared to the before period, there were lower rates of CPR, higher rates of successful CPR, shorter lengths of stay, and lower hospital mortality.

Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions

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Perspective on Safety November 16, 2022

Human factors engineering or ergonomics (HFE) is a scientific discipline broadly focused on interactions among humans and other elements of a system.

In Conversation with Dr. Michelle Schreiber on Measuring Patient Safety

We spoke to Dr. Michelle Schreiber about measuring patient safety, the CMS National Quality Strategy, and the future of measurement. Michelle Schreiber, MD, is the Deputy Director of the Center for Clinical Standards and Quality and the Director of the Quality Measurement and Value-Based Incentives Group at the Centers for Medicare & Medicaid Services.

Critical care resource nurse team: a patient safety and quality outcomes model.

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Patient Safety Innovation November 16, 2022

Rapid response teams are intended to improve timely identification and management of clinically deteriorating patients, such as in-hospital cardiac arrest or stroke.

Improving communication and response to clinical deterioration to increase patient safety in the intensive care unit.

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Liu SI, Shikar M, Gante E, et al. Crit Care Nurse. 2022;42:33-43.

Lack of communication between providers can contribute to failure to rescue. Following a series of deaths due in part to not identifying clinical deterioration in a timely manner and/or not escalating care, this surgical intensive care unit (SICU) implemented an interdisciplinary quality improvement intervention. The intervention consisted of educating nurses on conditions necessitating escalation, multidisciplinary rounds with night staff, and an escalation document in the electronic health record (EHR).

Association of rapid response teams with hospital mortality in Medicare patients.

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Girotra S, Jones PG, Peberdy MA, et al. Circ Cardiovasc Qual Outcomes. 2022;15:e008901.

Rapid response teams (RRTs) have been implemented at hospitals worldwide, despite mixed results in their effectiveness. The aim of this study was to compare expected mortality rates with mortality rates following RRT implementation, adjusted for hospital case mix. Of 56 hospitals that participated in this project and had complete data, only four showed lower-than-expected mortality rates and two showed higher-than-expected mortality, suggesting RRT may not reduce mortality rates as much as earlier studies have reported.

Exploration of a rapid response team model of care: a descriptive dual methods study.

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Shiell A, Fry M, Elliott D, et al. Intensive Crit Care Nurs. 2022;73:103294.

Rapid response team (RRT) activations bring together a team of providers to immediately assess and treat a patient who is rapidly deteriorating. This mixed-methods study examined the characteristics of a collaborative RRT model in one Australian tertiary care hospital. The majority of activations occurred in general medicine units and some patients (approximately 5%) had more than five activations. Qualitative interviews with nurses and physicians highlighted how the collaborative RRT model improves patient safety and optimized early detection and management of patient deterioration.

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