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 13368 Results

In Conversation with Connor Wesley, RN, BSN on Patient Safety Concerns and the LGBTQ+ Population

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Perspective on Safety February 1, 2023

Connor Wesley, RN, BSN, is a registered nurse in Tacoma, WA. In addition to his role as the Assistant Nurse Manager of the Emergency Department at MultiCare Allenmore Hospital, Connor lectures locally and nationally on providing healthcare to members of the lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ+) community. We interviewed Connor to discuss patient safety and the LGBTQ+ community.

Leadership behavior associations with domains of safety culture, engagement, and healthcare worker well-being.

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Tawfik DS, Adair KC, Palassof S, et al. Jt Comm J Qual Patient Saf. 2022;Epub Dec 23.

Leadership across all levels of a health system plays an important role in patient safety. In this study, researchers administered the Safety, Communication, Operational, Reliability, and Engagement (SCORE) survey to 31 Midwestern hospitals to evaluate how leadership behaviors influenced burnout, safety culture, and engagement. Findings indicate that local leadership behaviors are strongly associated with healthcare worker burnout, safety climate, teamwork climate, workload, and intentions to leave the job.

Cost of inpatient falls and cost-benefit analysis of implementation of an evidence-based fall prevention program.

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Dykes PC, Curtin-Bowen M, Lipsitz S, et al. JAMA Health Forum. 2023;4:e225125.

Patient falls are associated with poorer clinical outcomes, and increased costs to the health system. This study describes the economic costs of implementing the Fall Tailoring Interventions for Patient Safety (Fall TIPS) Program in eight American hospitals. Results show the Fall TIPS program reduced falls by 19%, avoiding over $14,000 of costs per 1,000 patient days.

Surgical site infection prevention: a review.

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Seidelman JL, Mantyh CR, Anderson DJ. JAMA. 2023;329:244-252.

Surgical site infections (SSIs) remain a significant cause of preventable post-operative morbidity and mortality. This narrative review summarizes modifiable and nonmodifiable patient-related factors. It also evaluates modifiable operation-related factors associated with surgical site infections, and highlights six pre-, intra-, and postoperative strategies to reduce surgical site infections, including use of the WHO surgical safety checklist.

Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts.

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WebM&M Case February 1, 2023

A 38-year-old man with end-stage renal disease (ESRD) on chronic hemodialysis was admitted for nonhealing, infected lower leg wounds and underwent a below-knee amputation. He suffered from postoperative pain at the operative stump and was treated for four days with regional nerve blocks, as well as gabapentin, intermittent intravenous hydromorphone (which was transitioned to oral oxycodone) and oral hydromorphone.

Persisting high rates of omissions during anesthesia induction are decreased by utilization of a pre- & post-induction checklist.

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Krombach JW, Zürcher C, Simon SG, et al. Anaesth Crit Care Pain Med. 2022;42:101186.

Checklists have been highlighted as a cognitive aid to decrease omissions of care in surgery and other routine and critical events. This study evaluated a pre- and post-anesthesia induction checklist to determine the omission rate and impact on patient safety. Use of the checklist reduced omission rates significantly during both pre- and post-induction periods. However omission remained high at 32% and 40%, respectively and use of the checklists remained low.

"Do no harm": promoting anti-racist policing in pediatric emergency departments through 20 practice change considerations.

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Wells JM, Walker VP. Health Promot Pract. 2023:152483992211451.

Addressing racism in healthcare is a patient safety priority. This article discusses how an active presence by hospital threat management systems (e.g., hospital-employed security, local law enforcement personnel) in pediatric emergency departments (EDs) can help ensure patient safety but also contributes to unsafe care due to racial stereotypes and threat perception among minority patients and caregivers. The authors outline patient-centered strategies at the individual-, intra-organizational-, and extra-organizational levels for responding to disruptive and violent events.

Self-assessment and learning motivation in the second victim phenomenon.

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Bushuven S, Trifunovic-Koenig M, Bentele M, et al. Int J Environ Res Public Health. 2022;19:16016.

Healthcare workers (HCWs) who are involved in serious adverse events may feel traumatized by those events, and many organizations have implemented “second victim” training programs to support their workers. This study sought to understand HCWs’ motivations to attend such trainings and a potential association with overconfidence. Understanding the association may help organizations develop effective training programs and increase motivation to attend them.

Speaking up during the COVID-19 pandemic: nurses' experiences of organizational disregard and silence.

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Abrams R, Conolly A, Rowland E, et al. J Adv Nurs. 2023;Epub Jan 16.

Speaking up about safety concerns is an important component of safety culture. In this study, nurses in a variety of fields shared their experiences with speaking up during the COVID-19 pandemic. Three themes emerged: the ability to speak up or not, anticipated consequences of speaking up, and responses, or lack thereof, from managers.

Society for Maternal-Fetal Medicine Special Statement: telemedicine in obstetrics-quality and safety considerations

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Healy A, Davidson C, Allbert J, et al. Am J Obstet Gynecol. 2022;Epub Dec 5.

The demand for, and acceptance of, telemedicine solutions to provide services has grown substantially in recent years as safety profiles for the services are being defined. This guideline examines its use in pregnancy-related care, discusses the benefits and suggests actions to ensure patient safety during these encounters such as development of appropriate metrics and methods for vital-sign monitoring.

Nursing home patient safety culture perceptions among licensed practical nurses.

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Weaver SH, de Cordova PB, Ravichandran A, et al. J Nurs Care Qual. 2022;Epub Dec 7.

Nurse work environment has been linked to perceived safety culture and job satisfaction. This cross-sectional survey of licensed practical nurses (LPNs) in New Jersey found lower job satisfaction and perceived patient safety culture among LPNs working in nursing homes compared to LPNs working in other settings.

How providers can optimize effective and safe scribe use: a qualitative study.

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Corby S, Ash JS, Florig ST, et al. J Gen Intern Med. 2022;Epub Nov 16.

Medical scribes are increasingly being utilized to reduce the time burden on clinicians for electronic health record (EHR) documentation. In this secondary analysis, researchers identified three themes for safe use of medical scribes: communication aspects, teamwork efforts, and provider characteristics.

A deadly epidural, delivered by a doctor with a history of mistakes.

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Goldstein J. New York Times. January 23, 2023.

Active errors are evident when they occur, yet systemic weaknesses, if not addressed, allow them to repeat. This story examines poor epidural methods of one clinician that coincided with lack of organizational practitioner monitoring, unequitable maternal care for black women and clinician COVID fatigue to contribute to patient death.

The Joint Commission and National Quality Forum Announce 2022 Eisenberg Award Recipients.

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Oakbrook Terrace, IL: Joint Commission and National Quality Forum: January 23, 2023.

The annual Eisenberg Award recognizes leaders and organizations who have made substantial contributions toward patient safety and quality improvement. The 2022 honorees are Jason S. Adelman, MD, MS, North American Partners in Anesthesia (NAPA) and Parkland Health, Dallas County, Texas. The awards will be presented at the National Quality Forum's annual conference on February 20, 2023, in Washington, DC.

Explaining the negative effects of patient participation in patient safety: an exploratory qualitative study in an academic tertiary healthcare centre in the Netherlands.

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Van der Voorden M, Ahaus K, Franx A. BMJ Open. 2023;13:e063175.

Patient engagement in healthcare is widely encouraged, but findings from some studies suggest that patient participation can have negative effects. This qualitative study with 16 patients and obstetric healthcare professionals examined the negative effects of patient participation in healthcare. Researchers identified four types of negative consequences from patient participation in safety – decreases in patient confidence, eroding of the patient-professional relationship, unwanted increases in patient responsibility, and excess time spent by professionals on the patient.

The impact of TeamSTEPPS training on obstetric team attitudes and outcomes on the labor and delivery unit of a regional perinatal center.

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Kwon CS, Duzyj C. Am J Perinatol. 2022;Epub Dec 30.

Effective teamwork is critical for patient safety and numerous training strategies exist for improving team dynamics. The labor and delivery unit of an American hospital offered Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) training to all physicians and nurses on the ward, and assessed perceptions of teamwork and safety both before and six months after training. Results were mixed, and physician and nurse perceptions of safety significantly differed.

Patient and hospital characteristics associated with delayed diagnosis of appendicitis.

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Reyes AM, Royan R, Feinglass J, et al. JAMA Surg. 2023;Epub Jan 18.

Delays in diagnosis and treatment can lead to poor outcomes. In this population-based retrospective longitudinal study using inpatient and emergency department discharge data from four states, researchers found that non-Hispanic Black patients were at higher risk for delayed diagnosis of appendicitis compared to White patients. This increased risk for delayed diagnosis translated into higher risks for postoperative 30-day readmission rates. The researchers found that this risk was mitigated when Black patients received care at hospitals serving a more diverse patient population.

Long-Term Trends of Psychotropic Drug Use in Nursing Homes.

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Grimm CA. Washington DC: Office of the Inspector General; Nov 2022. Report no. OEI-07-20-00500.

Misdiagnosis can result in inappropriate medication use. This report examined the overuse of antipsychotics in nursing homes and resident harms. These recommendations from the U.S. Department of Health and Human Services Office of the Inspector General include heightened evaluation and oversight of medication use and better documentation of diagnosis with medication orders as avenues for improvement.

Bending the patient safety curve: how much can AI help?

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Classen DC, Longhurst CA, Thomas EJ. NPJ Digit Med. 2023;6:2.

Artificial Intelligence (AI) is used in an increasing range of health care situations to address a variety of care needs. This commentary examines the impact of AI on patient safety, in diagnosis, and on the limitations of AI that affect reliability.

Hospital-Acquired Diabetic Ketoacidosis.

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WebM&M Case February 1, 2023

This WebM&M highlights two cases of hospital-acquired diabetic ketoacidosis (DKA) in patients with type 1 diabetes. The commentary discusses the role of the inpatient glycemic team to assist with diabetes management, the importance of medication reconciliation in the emergency department (ED) for high-risk patients on insulin, and strategies to empower patients and caregivers to speak up about medication safety.

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