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 938 Results

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

Top 10 Patient Safety Concerns.

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Plymouth Meeting, PA: ECRI; March 2023.

The global COVID-19 pandemic continues to exacerbate weaknesses in care that can contribute to harm. ECRI presents the top ten patient concerns for 2023, including pediatric mental health care, workplace violence, care coordination, and patient medication list mistakes.

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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.

Fatigue in nurses and medication administration errors: a scoping review.

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Bell T, Sprajcer M, Flenady T, et al. J Clin Nurs. 2023;Epub Jan 27.

Fatigue is a known contributor to adverse events and near misses. Researchers summarized 38 studies on the impact of fatigue on nurses’ medication administration errors (MAE) or near misses. Thirty-one studies reported that long hours, shift work, overtime, and/or poor sleep quality contributed to MAE and near miss, but results and methods of measuring fatigue were inconsistent.

Impact of medical education on patient safety: finding the signal through the noise.

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Hwang J, Kelz RR. BMJ Qual Saf. 2023;32:61-64.

Patient safety improvements must consider the complexities of care delivery to achieve lasting change. This commentary discusses recent evidence examining the effect of duty hour limit adjustments. The authors highlight challenges regarding research design on this medical education policy change and how it affects learner and patient experience. They suggest caution in applying the study conclusions.

On Patient Safety.

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Järvinen TLN, Rickert J, Lee MJ, et al. Clin Orthop Relat Res. 2013-2023.

This quarterly commentary explores a wide range of subjects associated with patient safety, such as the impact of disruptive behavior on teams, the value of apologies, and safety challenges due to COVID-19. Older materials are available online for free.

Work environment and operational failures associated with nurse outcomes, patient safety, and patient satisfaction.

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Riman KA, Harrison JM, Sloane DM, et al. Nurs Res. 2023;72:20-29.

Operational failures – breakdowns in care processes, such as distractions or situational constraints – can impact healthcare delivery. This cross-sectional analysis using population-based survey data from 11,709 nurses examined the relationship between operational failures, patient satisfaction, nurse-reported quality and safety, and nurse job outcomes. Findings indicate that operational failures negatively impact patient satisfaction, quality and safety, and contribute to poor nurse job outcomes, such as burnout.

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.

Urgent referrals from primary care to dermatology for lesions suspicious for skin cancer: patterns, outcomes, and need for systems improvement.

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Pagani K, Lukac D, Olbricht SM, et al. Arch Dermatol Res. 2022;Epub Nov 10.

Delayed referrals from primary care providers to specialty care can lead to delayed diagnoses and patient harm. This retrospective analysis examined differences in timely versus delayed referrals for urgent skin cancer evaluations at one institution. Among 320 referrals occurring in 2018, 38% of evaluations occurred 31 days or more after the referral and nearly 11% of referrals were never completed. Delayed referrals were more common among patients who did not speak English and racial/ethnic minorities.

The impact of health care strikes on patient mortality: a systematic review and meta-analysis of observational studies.

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Essex R, Weldon SM, Thompson T, et al. Health Serv Res. 2022;57:1218-1234.

A systematic review in early 2022 revealed healthcare worker strikes may negatively impact patient safety but also result in long-term benefits. This review by the same authors explores the impact of strikes on in-hospital and population mortality. None of the 11 studies examining in-hospital mortality reported a significant difference between mortality during the strike compared to the control period. Similarly, there was no difference in population mortality.

Critical care clinicians' experiences of patient safety during the COVID-19 pandemic.

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Rosen A, Carter D, Applebaum JR, et al. J Patient Saf. 2022;18:e1219-e1225.

The COVID-19 pandemic had wide-ranging impacts on care delivery and patient safety. This study examined the relationship between critical care clinician experiences related to patient safety during the pandemic and COVID-19 caseloads during the pandemic. Findings suggest that as COVID-19 caseloads increased, clinicians were more likely to perceive care as less safe.

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.

Catching those who fall through the cracks: integrating a follow-up process for emergency department patients with incidental radiologic findings.

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Patient Safety Innovation November 16, 2022

Appropriate follow-up of incidental abnormal radiological findings is an ongoing patient safety challenge. Inadequate follow-up can contribute to missed or delayed diagnosis, potentially resulting in poorer patient outcomes. This study describes implementation of an electronic health record-based referral system for patients with incidental radiologic finding in the emergency room.

Resident duty hours and resident and patient outcomes: systematic review and meta-analysis.

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Sephien A, Reljic T, Jordan J, et al. Med Educ. 2023;57:221-232.

The Accreditation Council for Graduate Medical Education (ACGME) includes work hour restrictions in its Common Program Requirements. The focus of this review is the impact of resident work hour restrictions on patient- and resident-level outcomes. Shorter shift hours were associated with some improved resident outcomes and but no association with patient outcomes.

Transparency, public reporting, and a culture of change to quality and safety in cardiac surgery.

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Ibrahim M, Szeto WY, Gutsche J, et al. Ann Thorac Surg. 2022;114:626-635.

Reports of poor care in the media or public reporting systems can serve as an impetus to overhauling hospitals or hospital units. After several unexpected deaths and a drop in several rating systems, this cardiac surgery department launched a comprehensive quality improvement review. This paper describes the major changes made in the department, including role clarity and minimizing variation in 24/7 staffing.

Prescribing decision making by medical residents on night shifts: a qualitative study.

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Lauffenburger JC, Coll MD, Kim E, et al. Med Educ. 2022;56:1032-1041.

Medication errors can be common among medical trainees. Using semi-structured qualitative interviews, this study identified factors influencing suboptimal prescribing by medical residents during overnight coverage, including time pressures, perceived pressure and fear of judgement, clinical acuity, and communication issues between care team members.

Trainee perceptions of resident duty hour restrictions: a qualitative study of online discussion forums.

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Dehmoobad Sharifabadi A, Clarkin C, Doja A. BMJ Open. 2022;12:e063104.

Several countries have resident duty hour (RDH) restrictions and there are numerous publications examining the impact of RDH on patient safety. This study used two online discussion forums (one primarily in the United States and the other in Canada) to assess resident perceptions of RDH. Themes included its impact on residents’ education and clinician well-being, and, worryingly, discussions of not reporting RDH violations.

A systematic review of nursing practice workarounds.

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McCord JL, Lippincott CR, Abreu E, et al. Dimens Crit Care Nurs. 2022;41:347-356.

Workarounds can pose significant risks to patient safety. This systematic review including 13 studies found that nursing workarounds most often occurred due to challenges in using the electronic health record (EHR) system or during medication administration.

Intravenous smart pumps at the point of care: a descriptive, observational study.

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Giuliano KK, Blake JWC, Bittner NP, et al. J Patient Saf. 2022;18:553-558.

Intravenous (IV) smart pumps can improve medication administration safety, but usability issues can compromise that safety. This study compared actual use of smart pumps to the manufacturer’s requirements for operation. Adherence to requirements was low and the authors present several recommendations to smart pump manufacturers. The Institute for Safe Medication Practices issued guidelines for safe use of smart pumps that address several of these safety concerns.

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Diagnostic Safety

October 10, 2022

Selected PSNet materials for a general safety audience focusing on improvements in the diagnostic process and the strategies that support them to prevent diagnostic errors from harming patients.

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