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 254 Results

Redesigning Event Review with RCA2

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Institute for Healthcare Improvement. September 13 - November 7, 2023.

Root cause analysis (RCA) is a widely recognized retrospective strategy for learning from failure that is challenging to implement. This series of webinars will feature an innovative approach to RCA that expands on the concept to facilitate its use in incident investigations. Instructors for the series will include Dr. Terry Fairbanks and Dr. Tejal K. Gandhi.

Medication safety event reporting: factors that contribute to safety events during times of organizational stress.

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Cohen TN, Berdahl CT, Coleman BL, et al. J Nurs Care Qual. 2023;Epub May 9.

Institutional error and near-miss reporting helps identify systemic weaknesses and areas for improvement. COVID-19 presented a unique environment to study error reporting during organizationally stressful times. In this study, incident reports of medication errors or near misses during a COVID-19 surge were analyzed. Skill-based (e.g., forgetting to administer a dose) and communication errors were the most common medication safety events.

Improving Diagnostic Safety and Quality

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Perspective on Safety April 26, 2023

Throughout 2022, AHRQ PSNet has shared research that elucidates the complex nature of misdiagnosis and diagnostic safety. This Year in Review explores recent work in diagnostic safety and ways that greater safety may be promoted using tools developed to improve diagnostic practices.

Development and interrater agreement of a novel classification system combining medical and surgical adverse event reporting.

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Stone A, Jiang ST, Stahl MC, et al. JAMA Otolaryngol Head Neck Surg. 2023;149:424-429.

Identifying and classifying adverse events is an important, yet often challenging, component of incident reporting. This article describes the development and testing of a novel Quality Improvement Classification System (QICS) designed to incorporate adverse events in both inpatient and outpatient settings across medical and surgical specialties in order to capture a broader range of outcomes related to patient care, including organizational issues, near-miss events, and expected deviations from ideal outcomes of surgery.

Linking patient safety climate with missed nursing care in labor and delivery units: findings from the LaborRNs survey.

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Zhong J, Simpson KR, Spetz J, et al. J Patient Saf. 2023;19:166-172.

Missed nursing care is a key indicator of patient safety and has been linked to safety climate. Survey responses from 3,429 labor and delivery nurses from 253 hospitals across the United States found an average of 11 of 25 aspects of essential nursing care were occasionally, frequently, or always missed. Higher perceived safety climate was associated with less missed care. The authors discuss the importance of strategies to reduce missed care, such as adequate nurse staffing, ensuring nonpunitive responses to errors, and promoting open communication.

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.

Impact of System Failures on Healthcare Workers

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Perspective on Safety March 21, 2023

Throughout 2022, the impact of system failures on healthcare workers was a recurrent theme of articles on AHRQ PSNet. This Year in Review explores these impacts and ways to support healthcare workers involved in a system failure.

Near-miss events detected using the emergency department trigger tool.

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Griffey RT, Schneider RM, Todorov AA. J Patient Saf. 2023;19:59-66.

Near-miss incidents present useful learning opportunities but frequently go unreported. This study used a computerized trigger tool to identify near-miss incidents in the emergency department (ED). Results show approximately 23% of ED visits during the 13-month study period included a near-miss incident. This analysis suggests computerized trigger tools can be useful to identify near misses that otherwise go unreported.

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.

Nursing student errors and near misses: three years of data.

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Silvestre JH, Spector ND. J Nurs Educ. 2023;62:12-19.

Learning from mistakes is an essential component of medical and nursing education. This retrospective study examined medical errors and near-misses committed by nursing students at more than 200 prelicensure programs. Of the 1,042 errors and near-misses reported, medication errors were most common (59%). Three primary contributing factors to errors and near-miss events were identified – (1) not checking patient identification, (2) not checking a patient’s allergy status, and (3) not following the “rights” of medication administration.

A customized triggers program: a children's hospital's experience in improving trigger usability.

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Reinhart RM, Safari-Ferra P, Badh R, et al. Pediatrics. 2023;151:e2022056452.

Trigger tools are widely used for detecting potential adverse events among adult and pediatric inpatients. This article describes the development of a pediatric triggers program that can identify potential adverse events in near real-time to facilitate appropriate preventative measures. The tool includes criteria from the IHI Global Trigger Tool as well as novel triggers (such as pain reassessment time, hospital readmissions, and suspected sepsis). The trigger team created a process for linking triggers to the organizational incident reporting system based on specific criteria (to reduce false-positive reports). The trigger team is continuously developing and refining triggers based on stakeholder input.

The value of learning from near misses to improve patient safety: a scoping review.

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Woodier N, Burnett C, Moppett I. J Patient Saf. 2022;19:42-47.

Reporting and learning from adverse events is a core patient safety activity. Findings from this scoping review indicate limited evidence demonstrating that reporting and learning from near-miss events improves patient safety. The authors suggest that future research further explore this relationship and establish the effectiveness of system-level actions to avoid near misses.

Examination of maternal near-miss experiences in the hospital setting among Black women in the United States.

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Byrd TE, Ingram LA, Okpara N. Womens Health (Lond). 2022;18:174550572211338.

Maternal near misses are associated with lower quality of life and poorer outcomes for the pregnant person and their family. In this study, 12 Black women who experienced a maternal near miss describe major contributors. They list communication problems, such as not being believed, their relationship with their provider, and provider discrimination as major contributors.

Resilient Healthcare and the Safety-I and Safety-II Frameworks

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Perspective on Safety December 14, 2022

This piece discusses resilient healthcare and the Safety-I and Safety-II approaches to patient safety.

In conversation with Ellen Deutsch, MD, MS, FACS, FAAP, FSSH, CPPS

Ellen Deutsch, MD, MS, FACS, FAAP, FSSH, CPPS is a Medical Officer in the Center for Quality Improvement and Patient Safety at the Agency for Healthcare Research and Quality. Dr. Deutsch is a pediatric otolaryngologist and has vast experience in simulation and resilience engineering. We spoke with her about resilient healthcare and how resilient engineering principles are applied to improve patient safety.

A multicenter collaborative effort to reduce preventable patient harm due to retained surgical items.

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Carmack A, Valleru J, Randall KH, et al. Jt Comm J Qual Patient Saf. 2023;49:3-13.

Retained surgical items (RSI) are a never event, a serious and preventable event. After experiencing a high rate of RSIs, this United States health system implemented a bundle to reduce RSI, improve near-miss reporting, and increase process reliability in operating rooms. The bundle consisted of five elements: surgical stop, surgical debrief, visual counters, imaging, and reporting.

Influencing a culture of quality and safety through huddles.

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McCain N, Ferguson T, Barry Hultquist T, et al. J Nurs Care Qual. 2023;38:26-32.

Daily huddles can improve team communication and awareness of safety incidents. This single-site study found that implementation of daily interdisciplinary huddles increased reporting of near-miss events and improved team satisfaction and perceived team communication, collaboration, and psychological safety.

The impact of COVID-19 workflow changes on radiation oncology incident reporting.

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Volpini ME, Lekx‐Toniolo K, Mahon R, et al. J Appl Clin Med Phys. 2022;23:e13742.

The COVID-19 pandemic dramatically impacted the way that health care teams function. This study examined how COVID-19-related workflow changes affected reporting of medical errors and near misses occurring in one hospital’s radiation oncology program. After the onset of the COVID-19 pandemic, there was fewer incidents reported overall, but an increase in submissions related to poor documentation and communication.

False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy.

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WebM&M Case October 27, 2022

A 47-year-old man underwent a navigational bronchoscopy with transbronchial biospy under general anesthesia without complications. The patient was transferred to the post-acute care unit (PACU) for observation and a routine post-procedure chest x-ray (CXR). After the CXR was taken, the attending physician spoke to the patient and discussed his impressions, although he had not yet seen the CXR. He left the PACU without communicating with the bedside nurse, who was caring for other patients. The patient informed the nurse that the attending physician had no concerns.

When medical error becomes personal, activism becomes painful.

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Millenson M. Forbes. September 16, 2022.

Unnecessary medication infusions indicate weaknesses in medication service processes. While no harm was noted in the case discussed, the actions by the patient’s family to initiate an examination of the incident were rebuffed, patient disrespect was demonstrated, a near miss incident report was absent, and data omissions took place. The piece discusses how these detractors from safety were all present at the hospital involved.

Reducing near miss medication events using an evidence-based approach.

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Smith-Love J. J Nurs Care Qual. 2022;37:327-333.

Barcode medication administration (BCMA) is one approach to reducing near-miss medication safety events. Researchers used a FOCUS (find-organize-clarify-understand-select) PDSA (plan-do-study-act) methodology to help frontline nursing staff identify gaps in care processes and root causes contributing to poor compliance with barcode medication administration.

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