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 11857 Results

The Ohio Maternal Safety Quality Improvement Project: initial results of a statewide perinatal hypertension quality improvement initiative implemented during the COVID-19 pandemic.

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Schneider P, Lorenz A, Menegay MC, et al. Am J Obstet Gynecol MFM. 2023;5:100912.

Reducing maternal morbidity and mortality continues to be a patient safety priority in the United States. The article describes the implementation of a quality improvement initiative in Ohio to improve outcomes for patients with a severe hypertensive event during pregnancy or postpartum. Among 29 participating hospitals between July 2020 and September 2021, the researchers identified sustained improvements in timely and appropriate treatment for severe hypertension, timely follow-up appointment after hospital discharge, and patient education about urgent maternal warning signs across both non-Hispanic Black and White pregnant or postpartum people.

Incidence and outcomes of non-ventilator-associated hospital-acquired pneumonia in 284 US hospitals using electronic surveillance criteria.

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Jones BE, Sarvet AL, Ying J, et al. JAMA Netw Open. 2023;6:e2314185.

Pneumonia is one of the most common healthcare-acquired infections and can result in significantly longer lengths of stay and increased costs. In this retrospective study of more than six million hospitalized Veterans Health Administration patients, approximately 1 in 200 patients developed non-ventilator-associated hospital-acquired pneumonia (NV-HAP). Length of stay and mortality were significantly higher for patients with NV-HAP.

Care Post-Roe: Documenting Cases of Poor-quality Care Since the Dobbs Decision.

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Grossman D, Joffe C, Kaller S, et al. Advancing New Standards in Reproductive Health, University of California, San Francisco; 2023.

Overarching policy decisions have the potential to impact systems of care and harm patients. This document reports the preliminary findings of a study examining 50 cases submitted where clinicians modified care standards in response to abortion access limitations. The changes affected the timeliness, quality, safety, cost, and complexity of care delivered to pregnant patients.

Adolescents identifying errors and omissions in their electronic health records: a national survey.

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Hagström J, Blease CR, Kharko A, et al. Stud Health Technol Inform. 2023;302:242-246.

Patients are increasingly able to access their health record via electronic patient portals and many report finding errors in the record. This study asked adolescent (ages 15-19) patient portal users if they had identified errors or omissions in their record, and if so, did they report them to their provider. Approximately one-quarter of patients identified an error and 20% identified an omission. The majority of those patients did not report it to the clinic or healthcare provider.

A national safety board made transportation safer and could do the same for health care, advocates say.

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Jaklevic MC. CNN. May 30, 2023.

Patient safety has long drawn from aviation safety strategies to inform improvement. This article examines the potential for transparency and learning should a National Patient Safety Board be established in the United States. Like the National Transportation Safety Board concept, the proposed agency would collect data on facilities where errors occurred, which is discussed as a barrier to acceptance of the safety board approach in health care.

Impact of a computerized physician order entry system on medication safety in pediatrics-The AVOID study.

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Wimmer S, Toni I, Botzenhardt S, et al. Pharmacol Res Perspect. 2023;11:e01092.

Computerized physician order entry (CPOE) systems can prevent medication ordering and dispensing errors. This pre-post study compared medication safety outcomes for paper-based prescribing versus CPOE-based prescribing among pediatric patients at one German hospital. The researchers found that CPOE implementation resulted in fewer potentially harmful medication errors.

Classification of health information technology safety events in a pediatric tertiary care hospital.

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Khan A, Karavite DJ, Muthu N, et al. J Patient Saf. 2023;19:251-257.

For incidents to be properly addressed, incident reports must be appropriately identified and categorized by safety managers. This study compared the categorization of incidents as involving health information technology (HIT) or not involving HIT by specialists trained in HIT and patient safety and safety managers trained in traditional methods of health safety. Safety managers only agreed with the HIT specialist classification 25% and 75% of the time on incidents involving or not involving HIT, respectively. Increased education for safety managers on the interaction of HIT and patient safety may result in better classification of HIT-related incidents.

People for Patient Safety.

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PULSE Center for Patient Safety Education & Advocacy. Second Monday of every month; 7:00 PM (eastern).

Patient advocates and caregivers play a valuable role in keeping patients safe. This reoccurring session provides a communication forum for individuals to discuss topics and shared experiences as they support patient safety. The next monthly session will be held June 12, 2023.

Analysis of the nature and contributory factors of medication safety incidents following hospital discharge using National Reporting and Learning System (NRLS) data from England and Wales: a multi-method study.

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Alqenae FA, Steinke DT, Carson-Stevens A, et al. Ther Adv Drug Saf. 2023;14:204209862311543.

Medication errors and adverse drug events (ADE) are unfortunately common at hospital discharge. This study used the National Reporting and Learning System (NRLS) in England and Wales to identify contributing causes to medication errors and ADE. Patients over 65 were the most common age group and, of incidents with a stated level of harm, most did not result in any harm. Overall, most incidents occurred at the prescribing stage, but varied by patient age group. Most contributory factors were organizational (e.g., continuity of care between provider types), followed by staff, patient, and equipment factors.

'Speaking Up' for patient safety and staff well-being: a qualitative study.

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Delpino R, Lees-Deutsch L, Solanki B. BMJ Open Qual. 2023;12:e002047.

Following the 2013 release of the Report of The Mid Staffordshire NHS Foundation Trust inquiry, National Health Service (NHS) Trusts have made substantial efforts to increase staffs’ willingness to speak up about patient safety concerns. One method is the creation of confidential resources who provide staff support: Freedom to Speak Up Guardians (FTSUG) and Confidential Contacts (CC). This study explored perspectives of FTSUG and CC on how they best support staff and how leaders can encourage speaking up behavior.

Clinical nurse competence and its effect on patient safety culture: a systematic review.

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Zaitoun RA, Said NB, de Tantillo L. BMC Nurs. 2023;22:173.

Nurses play an important role in ensuring patient safety. This systematic review identified 16 studies examining the relationship between nursing competence and safety culture. The researchers identified several gaps in the evidence, including the need for rigorous research measuring the association between safety culture and nursing safety competencies and evaluating the effect of nursing safety competency on safety culture scores.

Perception of feeling safe perioperatively: a concept analysis.

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Larsson F, Strömbäck U, Rysst Gustafsson S, et al. Int J Qual Stud Health Well-being. 2023;18:2216018.

Patients expect to "feel safe" in healthcare settings. This concept analysis describes defining attributes (participation, control, presence) of patients in the perioperative environment. Through a series of cases that include all, some, or none of the safety attributes, the authors illustrate the concept of patients "feeling safe" in the perioperative environment.

Explicitly addressing implicit bias on inpatient rounds: student and faculty reflections.

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Carter RG, Lake S. Pediatrics. 2023;151.

This commentary co-written by a medical student and a faculty member explores the presence and impact of implicit bias on the clinician team and patients. The piece introduces a four-step framework through which to examine the origins of bias, how its described, its care impact and how to reduce its effect.

Understanding medication safety involving patient transfer from intensive care to hospital ward: a qualitative sociotechnical factor study.

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Bourne RS, Jeffries M, Phipps DL, et al. BMJ Open. 2023;13:e066757.

Patients transitioning from the intensive care unit (ICU) to the general ward are vulnerable to medication errors. This qualitative study included medical staff and clinical pharmacists from hospital wards and ICUs to identify factors that contribute to medication safety or adverse events at times of transition. Lack of communication between provider types (e.g., nurse and pharmacist) and time pressure considerations had negative effects on medication safety. Ward rounds and safety culture had positive effects.

A scoping review of distributed cognition in acute care clinical decision-making.

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Wilson E, Daniel M, Rao A, et al. Diagnosis (Berl). 2023;10:68-88.

Clinical decision-making is a complex process often involving interactions with multiple team members, processes, and systems. Using distributed cognition theory and qualitative synthesis, this scoping review including 37 articles identified seven themes addressing how distribution of tasks influences clinical decision-making in acute care settings The themes included information flow, task coordination, team communication, situational awareness, electronic health record (EHR) design, systems-level error, and distributed decision-making.

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

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Patient Safety Innovation May 31, 2023

Seeking a sustainable process to enhance their hospitals’ response to sepsis, a multidisciplinary team at WellSpan Health oversaw the development and implementation of a system that uses customized electronic health record (EHR) alert settings and a team of remote nurses to help frontline staff identify and respond to patients showing signs of sepsis. When the remote nurses, or Central Alerts Team (CAT), receive an alert, they assess the patient’s information and collaborate with the clinical care team to recommend a response.

Strategies to Improve Organizational Health Literacy.

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Patient Safety Primer May 31, 2023

Anyone can find it challenging to understand medical terms, and millions of Americans have trouble understanding and acting upon health information. Health literate organizations make health systems easier to navigate and health information easier to understand, improving healthcare delivery and outcomes.

Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans

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Patient Safety Innovation May 31, 2023

Patient falls in hospitals are common and debilitating adverse events that persist despite decades of effort to minimize them. Improving communication across the assessing nurse, care team, patient, and patient’s most involved friends and family may strengthen fall prevention efforts. A team at Brigham and Women’s Hospital in Boston, Massachusetts, sought to develop a standardized fall prevention program that centered around improved communication and patient and family engagement.

Patients admitted on weekends have higher in-hospital mortality than those admitted on weekdays: analysis of national inpatient sample.

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Manadan A, Arora S, Whittier M, et al. Am J Med Open. 2023;9:100028.

The ”weekend effect” refers to worse outcomes among patients admitted on the weekend versus weekday. Based on a sample of over 121 million adult hospital discharges from 2016 to 2019, researchers examined the association between several different variables and in-hospital death. Multivariable analyses identified several predictors of in-hospital death (e.g., older age, higher number of comorbidities, etc.) and the researchers found that patients admitted on weekends underwent fewer procedures and had higher mortality rates compared to patients admitted on weekdays. The authors suggest that improved staffing and availability of procedures may improve mortality.

Effect of an emergency department process improvement package on suicide prevention: the ED-SAFE 2 cluster randomized clinical trial.

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Boudreaux ED, Larkin C, Vallejo Sefair A, et al. JAMA Psych. 2023;Epub May 17.

Patients who present to the emergency department (ED) with suicidal ideation can benefit from ED-initiated interventions, but interventions can be difficult to implement and maintain. This research builds on a 2013 study, describing the quality improvement (QI) methods used to implement the Emergency Department Safety Assessment and Follow-up Evaluation 2 (ED-SAFE 2) trial. The QI approach was successful in reducing death by suicide and suicide-related acute care during the study period.

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