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 834 Results

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.

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.

The impact of nursing skill-mix on adverse events in intensive care: a single centre cohort study.

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Ross P, Hodgson CL, Ilic D, et al. Contemp Nurse. 2023;Epub May 8.

Improved nurse staffing ratios and nursing skill mix have been linked to improved safety outcomes. This retrospective cohort study of over 13,000 patients admitted to a tertiary intensive care unit (ICU) in Australia between 2016 and 2020 found that a great concentration of critical care registered nurses (CCRNs) was associated with a lower risk of adverse events.

Identification of patient safety threats in a post-intensive care clinic.

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Karlic KJ, Valley TS, Cagino LM, et al. Am J Med Qual. 2023;38:117-121.

Because patients discharged from the intensive care unit (ICU) are at increased risk of readmission and post-ICU adverse events, some hospitals have opened post-ICU clinics. This article describes safety threats identified by post-ICU clinic staff. Medication errors and inadequate medical follow-up made up nearly half of identified safety threats. More than two-thirds were preventable or ameliorable.

Error disclosure in neonatal intensive care: a multicentre, prospective, observational study.

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Passini L, Le Bouedec S, Dassieu G, et al. BMJ Qual Saf. 2023;Epub Mar 14.

Medical errors in the neonatal intensive care unit (NICU) are common and can result in significant patient harm. This prospective observational study conducted at 10 NICUs in France found that approximately 41% of the 1,822 errors (among 1,019 patients) were disclosed to the patient’s parents. Providers cited parental absence (i.e., the error occurred overnight) and perceived lack of serious consequences for the infant as the most frequent reason for non-disclosure.

Curated Libraries

Implementation of Patient Safety Projects Curated Library

May 4, 2023

The implementation of effective patient safety initiatives is challenging due to the complexity of the health care environment. This curated library shares resources summarizing overarching ideas and strategies that can aid in successful program execution, establishment, and sustainability.

Floating to intensive care units: nurses' messages for instant action to promote patient safety.

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Ahmed FR, Timmins F, Dias JM, et al. Nurs Crit Care. 2023;Epub Apr 1.

Staffing shortages are temporarily alleviated with floating or redeployed staff. This qualitative study of intensive care unit (ICU) critical care nurses and floating non-critical care nurses sought to identify the pros and cons of floating nurses, and strategies to improve patient safety. Floating nurses reported concerns surrounding unfamiliarity with the types of patients or locations of equipment. Critical care nurses reported cognitive overload with doing their routine duties plus orienting floating nurses. One recommendation to improve safety is competency-based nursing curriculum and provide floating nurses occasional training/experience in the ICU.

Using a learning system approach to improve safety for prone-position ventilation patients.

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Thomas AL, Graham KL, Davila S, et al. J Patient Saf. 2023;19:180-184.

The COVID-19 pandemic resulted in many changes to the delivery of healthcare. Using data submitted to one Patient Safety Organization, this study examined patient safety events and concerns related to proning patients during the COVID-19 pandemic. Issues identified included medical device-related pressure injuries and device dislodgement, concerns with care delivery, staffing levels, and acuity issues.

The relationship between patient safety culture and the intentions of the nursing staff to report a near-miss event during the COVID-19 crisis.

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Idilbi N, Dokhi M, Malka-Zeevi H, et al. J Nurs Care Qual. 2023;38:264-271.

If reported, near misses – also called “good catches” – present opportunities for healthcare organizations to learn about potential errors, identify system improvements, and improve safety culture. This mixed-methods study including 199 nurses, who worked in COVID-19 units, found that intent to report near misses was high (78%) but follow-through on reporting was low (20%). Qualitative analyses highlight the role that personnel/physical/mental overload, poor departmental organization, and fear of punitive measures play in underreporting near-miss events.

Difficult diagnosis in the ICU: making the right call but beware uncertainty and bias.

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Pisciotta W, Arina P, Hofmaenner D, et al. Anaesthesia. 2023;78:501-509.

A 2012 review estimated that diagnostic errors in the intensive care unit (ICU) may contribute to up to 8% of patient deaths. This narrative review identifies common causes of diagnostic error (e.g., cognitive bias) and suggests a diagnostic framework. Cognitive de-biasing strategies and increasing time spent with the patient are recommended as strategies for reducing diagnostic errors in this vulnerable patient population.

Prosocial voice in the hierarchy of healthcare professionals: the role of emotions after harmful patient safety incidents.

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Richmond JG, Burgess N. J Health Organ Manag. 2023;37:327-342.

Healthcare professionals who are involved in patient safety incidents can experience psychological distress. Using three case examples from surgery, urology, and maternity care, this study explored the emotional experience of healthcare professionals involved in patient safety incidents. The authors discuss the importance of providing support for recovery after involvement in a patient safety incident and protecting professionals from workplace pressures.

The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis

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Patient Safety Innovation March 15, 2023

During a time of unprecedented patient volume and clinical uncertainty, a diverse team of health system administrators and clinicians within the University of Pennsylvania Health System quickly investigated, updated, and disseminated airway management protocols after several airway safety incidents occurred among COVID-19 patients who were mechanically ventilated. Based on this experience, the team created the I-READI framework as a guide for healthcare systems to prepare for and quickly respond to quality and safety crises.¹

Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation

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WebM&M Case March 15, 2023

A 72-year-old man was diagnosed with COVID-19 pneumonia and ileus, and admitted to a specialized COVID care unit. A nasogastric tube (NGT) was placed, supplemental oxygen was provided, and oral feedings were withheld. Early in his hospital stay, the patient developed hyperactive delirium and pulled out his NGT. Haloperidol was ordered for use as needed (“prn”) and the nurse was asked to replace the NGT and confirm placement by X-ray. The bedside and charge nurses had difficulty placing the NGT and the X-ray confirmation was not done.

Critical care teamwork in the future: the role of TeamSTEPPS in the COVID-19 pandemic and implications for the future.

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Terregino CA, Jagpal S, Parikh P, et al. Healthcare (Basel). 2023;11:599.

The COVID-19 pandemic dramatically changed healthcare delivery and impacted the ways healthcare teams function. Using interprofessional focus groups, this study explored the perspectives of medical intensive care unit (MICU) team members on the role of TeamSTEPPS® during the first year of the COVID-19 pandemic. Participants discussed how TeamSTEPPS® impacted teamwork and communication through shared mental models, trust, role definition, and effective briefing/debriefing and transitions of care strategies. Participants also identified several challenges to TeamSTEPPS® implementation related to the MICU environment, the ongoing pandemic, power dynamics, and patient acuity.

Undertaking risk and relational work to manage vulnerability: acute medical patients' involvement in patient safety in the NHS.

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Sutton E, Martin G, Eborall H, et al. Soc Sci Med. 2023;320:115729.

Patient engagement is cornerstone to safe care initiatives. This qualitative study including 28 acute care patients explored how patients contribute to safety and highlight the importance of reassurance and vigilance.

Curated Libraries

Value and Patient Safety

March 8, 2023

Value as an element of patient safety is emerging as an approach to prioritize and evaluate improvement actions. This library highlights resources that explore the business case for cost effective, efficient and impactful efforts to reduce medical errors.

Recognizing our biases, understanding the evidence, and responding equitably: application of the socioecological model to reduce racial disparities in the NICU.

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McCarty DB. Adv Neonatal Care. 2023;23:31-39.

Racism is increasingly seen as a major contributor to poor maternal care and adverse outcomes. This article summarizes racial health disparities impacting patients in the neonatal intensive care unit (NICU) and interventions to reduce racial bias in the NICU.

Association between unmet nonmedication needs after hospital discharge and readmission or death among acute respiratory failure survivors: a multicenter prospective cohort study.

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Bose S, Groat D, Dinglas VD, et al. Crit Care Med. 2023;51:212-221.

Medication discrepancies at discharge are a known contributor to hospital readmission, but nonmedication needs may also contribute. In this study, 200 survivors of acute respiratory failure were followed up 7-28 days post discharge to assess unmet nonmedication discharge needs (i.e., durable medical equipment, home health services, follow-up medical appointments). Nearly all patients had at least one unmet need, but this was not associated with hospital readmission or mortality within 90 days.

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