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 291 Results

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.

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.

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.

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.

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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London UK: Crown Copyright; March 30, 2022. ISBN: 9781528632294.

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.

Implementing a robust process improvement program in the neonatal intensive care unit to reduce harm.

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Nether KG, Thomas EJ, Khan A, et al. J Healthc Qual. 2022;44:23-30.

Medical errors in the neonatal intensive care unit threaten patient safety. This children’s hospital implemented a robust process improvement program (RPI, which refers to widespread dissemination of process improvement tools to support staff skill development and identify sustainable improvements) to reduce harm in the neonatal intensive care unit. The program resulted in significant and sustainable improvements to staff confidence and knowledge related to RPI tools. It also contributed to improvements in health outcomes, including healthcare-acquired infection.

Implementing a watcher program to improve timeliness of recognition of deterioration in hospitalized children

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Patient Safety Innovation April 7, 2022

A lack of situational awareness can lead to delayed recognition of patient deterioration. This children’s hospital developed and implemented a situational awareness framework designed to decrease emergency transfers to the intensive care unit (ICU).

Frequency of diagnostic errors in the neonatal intensive care unit: a retrospective cohort study.

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Shafer GJ, Singh H, Thomas EJ, et al. J Perinatol. 2022;42:1312-1318.

Patients in the neonatal intensive care unit (NICU) are at risk for serious patient safety threats. In this retrospective review of 600 consecutive inborn NICU admissions, researchers found that the frequency of diagnostic errors among inborn NICU patients during the first seven days of admission was 6.2%.

Proceed with reasonable care: when legal principles inform training to prevent harm during the childbirth.

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Petrovic M, Nicholls J, Siassakos D. Best Pract Res Clin Obstet Gynaecol. 2022;80:105-113.

Improving safe maternal care is an ongoing patient safety priority. This article outlines training strategies for providing safe obstetric care and improving communication among providers and patients.

Improving hospital infant safe sleep compliance by using safety prevention bundle methodology.

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Batra EK, Lewis ML, Saravana D, et al. Pediatrics. 2021;148:e2020033704.

Safety bundles are known to improve clinician adherence to guidelines and improve patient safety. This children’s hospital implemented a safe sleep bundle in all departments to reduce sudden unexpected infant deaths. Overall compliance with safe sleep guidelines increased from 9% to 72%. Three individual components also improved (head of bed flat, sleep space free of extra items, and caregiver education completed); one measure, centerline for infant in supine position, remained stable. The safe sleep bundle was shown to be effective in improving infant sleep environments.

Curated Libraries

Medication/Drug Errors

January 14, 2022

The medication-use process is highly complex with many steps and risk points for error, and those errors are a key target for improving safety. This Library reflects a curated selection of PSNet content focused on medication and drug errors. Included resources explore understanding harms from preventable medication use, medication safety...

Safety, Equity and Engagement in Maternity Services.

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Newcastle upon Tyne, UK: Care Quality Commission; September 2021.

The safety of maternity care is threatened by inequity. This report analyzes a set of United Kingdom investigation reports to identify issues affecting maternity care to determine their prevalence elsewhere in the system. Problems identified include poor leadership and teamwork, as well as learning and cross-service collaboration.

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