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 423 Results

Perioperative Anaphylaxis After Insertion of a Latex Drain in a Patient with Known Latex Allergy

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WebM&M Case August 31, 2022

A 65-year-old female with a documented allergy to latex underwent surgery for right-sided Zenker’s diverticulum. Near the conclusion of surgery, a latex Penrose drain was placed in the neck surgical incision. The patient developed generalized urticaria, bronchospasm requiring high airway pressures to achieve adequate ventilation, and hypotension within 5 minutes of placement of the drain. The drain was removed and replaced with a silicone drain. Epinephrine and vasopressors were administered post-operatively and the patient’s symptoms resolved.

Preventing retained surgical items.

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Weston M, Chiodo C. AORN J. 2022;115:569-575.

Unintentionally retained foreign objects can be exacerbated by fatigue, distractions, and communication errors. This article highlights the importance of effective teamwork, high reliability orientation, and standardized surgical count methods to minimize the persistent problem of retained surgical items.

Compensation claims in Danish emergency care: identifying hot spots and blind spots in the quality of care.

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Morsø L, Birkeland S, Walløe S, et al. Jt Comm J Qual Patient Saf. 2022;48:271-279.

Patient complaints can provide insights into safety threats and system weaknesses. This study used the healthcare complaints analysis tool (HCAT) to identify and categorize safety problems in emergency care. Most problems arose during examination/diagnosis and frequently resulted in diagnostic errors or errors of omission.

The impact of "missed nursing care" or "care not done" on adults in health care: a rapid review for the Consensus Development Project.

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Willis E, Brady C. Nurs Open. 2022;9:862-871.

Incomplete nursing care can negatively affect care quality and safety. This rapid review found that missed or omitted nursing care in adults contributes to increased mortality, adverse events, and clinical deterioration. Included studies cited several causes (e.g., environmental factors, staffing levels and skill mix) as well as solutions (e.g., education, process redesign).

Annual Perspective: Topics in Medication Safety

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Perspective on Safety March 31, 2022

Errors in medication management and administration are major threats to patient safety. This piece explores issues with opioid and nursing-sensitive medication safety as well as medication safety in older adults. Future research directions in medication safety are also discussed.

She was headed to a locked psych ward. Then an ER doctor made a startling discovery.

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Boodman SG. Washington Post. February 12, 2022.

Misdiagnosis over a long period of time can be exacerbated by stigma and cognitive bias. This news story illustrates the problem of omissions due to potential stigma associated with patient mental health issues that contributed to a missed diagnosis. The author discusses how clinician experience led to flagging of a different testing approach to reveal a diagnosis that, once addressed, improved the patient's health.

Patient safety assurance in the age of defensive medicine: a review.

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Shenoy A, Shenoy GN, Shenoy GG. Patient Saf Surg. 2022;16:10.

Defensive medicine refers to clinician behaviors with the intent to avoid malpractice risk due to care omissions. This article provides an overview of defensive medicine and its relationship to the taxonomies of medical errors and the risks that defensive medicine places on patients, hospital administrators, and systems, as well as clinicians.

Non-conveyance of older adult patients and association with subsequent clinical and adverse events after initial assessment by ambulance clinicians: a cohort analysis.

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Lederman J, Lindström V, Elmqvist C, et al. BMC Emerg Med. 2021;21:154.

Patients who are treated by emergency medical services (EMS) personnel but not transported to the hospital are referred to as non-conveyed patients. In this retrospective cohort study, researchers found that older adult patients in Sweden are at an increased risk of adverse events (such as infection, hospitalization, or death) within 7-days following non-conveyance.

Factors associated with wrong blood in tube errors: an international case series - The BEST collaborative study.

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Dunbar NM, Kaufman RM. Transfusion (Paris). 2022;62:44-50.

Wrong blood in tube (WBIT) errors can be classified as intended patient drawn/wrong label applied or wrong patient/intended label applied. In this international study, errors were divided almost evenly between the two types and most were a combination of protocol violations (e.g. technology not used or not used appropriately) and slips/lapses (e.g., registration errors). Additional contributory factors and recommendations for improvement are also discussed.

Oops! I did it again: the psychology of everyday action slips.

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Mylopoulos M. Top Cogn Sci. 2022;14:282-329.

Unintentional unsafe actions such as slips can threaten patient safety. This article discusses “action slips” – failure to act as one intends in the context of habitual or routine action – and the psychological mechanisms underlying slips.

ISMP List of Error-Prone Abbreviations, Symbols, and Dose Designations.

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Horsham, PA; Institute for Safe Medication Practices; February 12, 2021.

A handy list for medical personnel to ensure and implement safe prescribing practices by avoiding use of these dangerous shortcuts.

Identification and safe storage of look-alike, sound-alike medicines in automated dispensing cabinets.

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Ruutiainen HK, Kallio MM, Kuitunen SK. Eur J Hosp Pharm. 2021;28:e151-e156.

Automated drug dispensing systems can reduce medication dispensing and administration errors. However, this study found that medication automated dispensing cabinets ADCs)in one hospital frequently contained look-alike, sound-alike (LASA) medications, which may increase the risk for medication error.

A qualitative study of prescribing errors among multi-professional prescribers within an e-prescribing system.

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Alshahrani F, Marriott JF, Cox AR. Int J Clin Pharm. 2020;43:884-892.

Computerized provider order entry (CPOE) can prevent prescribing errors, but patient safety threats persist. Based on qualitative interviews with multidisciplinary prescribers, the authors identified several issues related to CPOE interacting within a complex prescribing environment, including alert fatigue, remote prescribing, and default auto-population of dosages.

Bundle interventions including nontechnical skills for surgeons can reduce operative time and improve patient safety.

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Koike D, Nomura Y, Nagai M, et al. Int J Qual Health Care. 2020;32:522-530.

Nontechnical skills are gaining interest as one way to enhance surgical team performance and patient safety. In this single-center study, the authors found that a perioperative bundle that introduced nontechnical skills to the surgical team was effective in reducing operative time.

Omissions of care in nursing homes: a uniform definition for research and quality improvement.

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Mangrum R, Stewart MD, Gifford DR, et al. J Am Med Dir Assoc. 2020;21:1587-1591.e2.

Building upon earlier work, the authors engaged a technical expert panel to reach consensus on a definition for omissions of care in nursing homes. The article details the terms and concepts included in (and excluded from) the proposed definition, provides examples of omissions of care, intended uses (e.g., to guide quality improvement activities or training and education), and describes the implications of the definition for clinical practice, policy, and research.

Applying thematic synthesis to interpretation and commentary in epidemiological studies: identifying what contributes to successful interventions to promote hand hygiene in patient care.

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Drey N, Gould D, Purssell E, et al. BMJ Qual Saf. 2020;29:756-763.

This thematic analysis explored variations in the impact of hand hygiene interventions to prevent healthcare-associated infections. The analysis identified several directions for future research, including exploring ways to avoid the Hawthorne effect, embed the interventions into wider patient safety initiatives, and develop systematic approaches to implementation.

Association between surgeon technical skills and patient outcomes.

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Stulberg JJ, Huang R, Kreutzer L, et al. JAMA Surg. 2022;157:219-220.

This study examined variation in operative technical skills among patients undergoing colorectal and non-colorectal procedures and the association with patient outcomes. Higher technical skills were significantly associated with lower rates of complications, unplanned reoperations, and death or serious morbidity. The findings suggest that this skill variation accounts for more than 25% of the variation in patient outcomes.

Clinical reasoning in the wild: premature closure during the COVID-19 pandemic.

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Boyle JG, Walters MR, Jamieson S, et al. Diagnosis (Berl). 2020;7:177-179.

In this Letter to the Editor, the authors suggest that the COVID-19 pandemic presents a unique opportunity to consider how situational factors impact clinical reasoning performance and lead to errors. The authors discuss the potential implications through a clinical story involving a redeployed resident working in a COVID-19 assessment and treatment unit and an older man with respiratory symptoms.

Incoming interns recognize inadequate physical examination as a cause of patient harm.

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Russo S, Berg K, Davis J, et al. J Med Educ Curric Dev. 2020;7:238212052092899.

This study involving a survey of incoming interns found that nearly all medical interns believe that inadequate physical examination can lead to adverse events and that 45% have witnessed an adverse event due to inadequate examination. The authors propose a five-pronged intervention for improving physical examination training.

When the Indications for Drug Administration Blur

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WebM&M Case June 24, 2020

A 55-year old woman became unarousable with low oxygen saturation as a result of multiple intravenous benzodiazepine doses given overnight. The benzodiazepine was ordered following a seizure in the intensive care unit (ICU) and was not revised or discontinued upon transfer to the floor; several doses were given for different indications - anxiety and insomnia.

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