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 297 Results

Pediatric Diagnostic Safety: State of the Science and Future Directions.

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Grubenhoff JA, Cifra CL, Marshall T, et al. Rockville, MD: Agency for Healthcare Research and Quality; September 2023. AHRQ Publication No. 23-0040-5-EF.

Unique challenges accompany efforts to study and reduce diagnostic error in children. This issue brief discusses addressing obstacles associated with testing and care access limitations that affect diagnosis across a variety of pediatric care environments. It also provides recommendations for building capacity to advance pediatric diagnostic safety. This issue brief is part of a series on diagnostic safety.

Vital signs: maternity care experiences — United States, April 2023.

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Mohamoud YA, Cassidy E, Fuchs E, et al. MMWR Morb Mortal Wkly Rep. 2023;72:961–967.

Previous research has found that women often experience mistreatment and discrimination during maternity care. This CDC analysis of survey data for 2,402 respondents found that approximately one in five women experienced at least one type of mistreatment during maternity care (i.e., being ignored or refused, being shouted at or scolded, having their physical privacy violated). Nearly 29% of respondents reported experiencing at least one form of discrimination during their maternity care (i.e., age-, weight-, income-, or race/ethnicity-based discrimination).

Hiding in plain sight: inconvenient facts for patient safety in non-24/7 theatre on-site staffed obstetric units.

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McGurgan P. Aust N Z J Obstet Gynaecol. 2023;63:606-611.

Individual-, team-, and systems-based factors can affect safety during childbirth. This article discusses several patient safety threats that can hinder the safety of vaginal birth after cesarean (VAC) deliveries in high population density areas, including staffing and resource limitations, cultural and human factors, and patient communication.

Hospital bosses ignored months of doctors' warnings about Lucy Letby.

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Moritz J, Coffey J, Buchanan M. BBC News. August 19, 2023.

Whistleblowers can identify the presence of systemic failures, but the organization is responsible for acting on their reported concerns. This article summarizes the range of breakdowns that contributed to a British nurse serial murderer, who, despite warnings from others, continued to harm babies over several years.

2022 John M. Eisenberg Patient Safety and Quality Awards.

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Jt Comm J Qual Patient Saf. 2023;49(9):435-450.

The legacy of AHRQ leader John Eisenberg, MD, still inspires safety improvement work decades after his passing. This special issue highlights the efforts of the 2022 Eisenberg Award honorees and their impact on improving patient safety and quality. The 2022 award recipients coved here include Jason S. Adelman, MD, MS, and North American Partners in Anesthesia (NAPA).

Government Response to the Investigation into the Death of Elizabeth Dixon.

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Department of Health and Social Care. London, England: Crown Copyright; 2023

Following an investigation into the death of 11-month-old Elizabeth Dixon in the UK’s National Health System (NHS), a report with 12 recommendations for system improvement was released. This report sets out the government’s response to each recommendation, including the agency responsible for each recommendation, where applicable.

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;32:589-599.

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.

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.

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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.

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.

Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure.

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WebM&M Case February 1, 2023

A 5-day old male infant was admitted to the pediatric intensive care unit (PICU) and underwent surgery to correct a congenital heart defect. The patient’s postoperative course was complicated Staphylococcus aureus bacteremia and other problems, requiring venoarterial extracorporeal membrane oxygenation (VA-ECMO) and subsequent cardiac procedures.

Prevalence, causes and severity of medication administration errors in the neonatal intensive care unit: a systematic review and meta-analysis.

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Henry Basil J, Premakumar CM, Mhd Ali A, et al. Drug Saf. 2022;45:1457-1476.

Medication administration errors (MAEs) are thought to be common in neonatal intensive care units (NICUs). This systematic review estimated that the pooled prevalence of MAEs among patients in NICU settings ranged from 59% to 65%. The review highlights both active failures (e.g., similar drug packaging or names) and latent failures (e.g., noisy environments, inaccurate verbal or written orders) contributing to MAEs.

Implementation and facilitation of post-resuscitation debriefing: a comparative crossover study of two post-resuscitation debriefing frameworks.

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Kam AJ, Gonsalves CL, Nordlund SV, et al. BMC Emerg Med. 2022;22:152.

Debriefing after significant clinical events facilitates team-based communication, learning, and support. This study compared two post-resuscitation debriefing tools (Debriefing In Situ Conversation after Emergent Resuscitation Now [DISCERN] and Post-Code Pause [PCP]) following any intubation, resuscitation, or serious/unanticipated patient outcome in a children’s hospital. PCP was found to provide more emotional support and clinical learning, but there were no differences in the remaining categories.

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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.

A longitudinal study of a multifaceted intervention to reduce newborn falls while preserving rooming-in on a mother-baby unit.

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Whatley C, Schlogl J, Whalen BL, et al. Jt Comm J Qual Patient Saf. 2022;48:521-528.

Newborn falls or drops are receiving increasing attention as a patient safety issue. This article discusses a quality improvement initiative launched at one hospital aimed to decrease newborn falls through new parent education materials, a nursing risk assessment tool, and standardized reporting system. Three years after implementation, the hospital achieved one year without any newborn falls and there were no fall-related injuries over the three-year period.

Standardization of pediatric noncardiac operating room to intensive care unit handoffs improves communication and patient care.

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Hebballi NB, Gupta VS, Sheppard K, et al. J Patient Saf. 2022;18:e1021-e1026.

Handoffs from one care team to another present significant risks to the patient if essential patient information is not shared or understood by all team members. Stakeholders at this children’s hospital developed a structured tool for handoff between surgery and pediatric or neonatal intensive care units. Transfer of information and select patient outcomes improved, handoff time was unchanged, and attendance by all team members increased.

Experience of learning from everyday work in daily safety huddles: a multi-method study.

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Wahl K, Stenmarker M, Ros A. BMC Health Serv Res. 2022;22:1101.

Patient safety huddles generally use a Safety-I approach to learn from errors and increase team awareness about safety threats. This mixed-methods study found that patient safety huddles including a focus on learning from what works well (Safety-II) may be beneficial to healthcare organizations, particularly if they can purposely focus on learning from both negative and positive experiences.

Postdischarge adverse events among neonates admitted to the neonatal intensive care unit.

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Tsilimingras D, Natarajan G, Bajaj M, et al. J Patient Saf. 2022;18:462-469.

Post-discharge events, such as medication errors, can occur among pediatric patients discharged from inpatient settings to home. This prospective cohort, including infants discharged from one level 4 NICU between February 2017 and July 2019, identified a high risk for post-discharge adverse events, (including procedural complications and adverse drug events) and subsequent emergency department visits or hospital readmissions. Nearly half of these events were due to management, therapeutic, or diagnostic errors and could have been prevented.

Final Report of the Ockenden Review.

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Maternal and baby harm in healthcare is a sentinel event manifested by systemic failure. This report serves as the final conclusions of an investigation into 250 cases at a National Health System (NHS) trust. The authors share overarching system improvement suggestions and high-priority recommendations to initiate NHS maternity care improvement.

Diagnostic time-outs to improve diagnosis.

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Yale S, Cohen S, Bordini BJ. Crit Care Clin. 2022;38:185-194.

A broad differential diagnosis can limit missed diagnostic opportunities. This article outlines how diagnostic timeouts, which are intended reduce bias during the identification of differential diagnoses, can improve diagnosis and reduce errors.

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