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 212 Results

Why hospitals still make serious medical errors—and how they are trying to reduce them.

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Landro L. Wall Street Journal. March 12, 2023.

Patient harm from health care is persistent despite decades of effort to address problems that degrade care. This article discusses the potential that improved technology use has in reducing medication errors, falls, surgical errors, and high-risk hospital-acquired infections.

Demonstrating the value of a standardized cognitive assessment tool through the use of interprofessional rapid safety rounds.

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Patient Safety Innovation March 29, 2023

Cognitively impaired patients may be at increased risk of adverse events, such as falls, and assessment of cognitive status and implementation of appropriate supports is needed to improve their safety.

Enhancing Support for Patients’ Social Needs to Reduce Hospital Readmissions and Improve Health Outcomes

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Patient Safety Innovation March 29, 2023

With increasing recognition that health is linked to the conditions in which a patient lives, health systems are looking for innovative ways to support recently discharged patients in their lives outside of the hospital. In a recent innovation, Prime Healthcare Services, Inc., which includes a network of 45 hospitals, provided social needs assessments and strengthened its partnerships with community agencies to support the health of high-needs patients after their discharge from the hospital.

Patient perception of fall risk and fall risk screening scores.

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Solares NP, Calero P, Connelly CD. J Nurs Care Qual. 2023;38:100-106.

Falls in inpatient healthcare settings are a common patient safety event. This study including 201 older inpatient adults evaluated the relationship between the Johns Hopkins Fall Risk score and patient perceptions of fall risk. Researchers found that the greater the patient’s confidence in their ability to perform a high fall-risk behavior, the lower the fall-risk score.

Evaluation of effectiveness and safety of pharmacist independent prescribers in care homes: cluster randomised controlled trial.

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Holland R, Bond CM, Alldred DP, et al. BMJ. 2023;380:e071883.

Careful medication management in long-term care residents is associated with improved hospital readmission rates and reduced fall rates. In the UK, pharmacist independent prescribers (PIP) can initiate, change, or monitor medications, and this cluster randomized controlled trial evaluated the effect of PIPs on fall rates. After six months of PIP involvement, fall rates (the primary outcome) were not statistically different than the usual care group, although drug burden was reduced.

A scoping review of adverse incidents research in aged care homes: learnings, gaps, and challenges.

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St Clair B, Jorgensen M, Nguyen A, et al. Gerontol Geriatr Med. 2022;Epub Dec 20.

Older adults in long-term care settings can be vulnerable to patient safety incidents. This scoping review of 46 articles identified several gaps in the research on adverse events in long-term care and nursing home settings, including the absence of resident perspectives regarding safety and the role of interpersonal and environmental factors on the incidence of adverse events.

Exploring nursing-sensitive events in home healthcare: a national multicenter cohort study using a trigger tool.

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Nilsson L, Lindblad M, Johansson N, et al. Int J Nurs Stud. 2022;138:104434.

Nurse-sensitive outcomes are important indicators of nursing safety. In this retrospective study of 600 patient records from ten Swedish home healthcare organizations, researchers found that 74% of patient safety incidents were classified as nursing-sensitive and that the majority of those events were preventable. The most common types of nursing-sensitive events were falls, pressure injuries, healthcare-associated infections, and incidents related to medication management.

Interventions to increase patient safety in long-term care facilities-umbrella review.

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Świtalski J, Wnuk K, Tatara T, et al. Int J Environ Res Public Health. 2022;19:15354.

Improving patient safety in long-term care facilities is an ongoing challenge. This systematic review identified three types of interventions that can improve safety in long-term care facilities – (1) promoting safety culture, (2) reducing occupational stress and burnout, and (3) increasing medication safety.

Balancing safety, comfort, and fall risk: an intervention to limit opioid and benzodiazepine prescriptions for geriatric patients.

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Bloomer A, Wally M, Bailey G, et al. Geriatr Orthop Surg Rehabil. 2022;13:215145932211256.

Opioid use by older adults increases the risk of falls. This study examined electronic health record data to determine the proportion of older adults presenting to the emergency room or urgent care due to a fall who receive an opioid prescription, particularly those with at least one risk factor for misuse. Nearly one third of patients received a prescription for an opioid and/or benzodiazepine, and 11% had at least one risk factor for misuse.

Using community detection techniques to identify themes in COVID-19-related patient safety event reports.

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Boxley C, Krevat SA, Sengupta S, et al. J Patient Saf. 2022;18:e1196-e1202.

COVID-19 changed the way care is delivered to hospitalized patients and resulted in new categories and themes in patient safety reporting. This study used machine learning to group of more than 2,000 patient safety event (PSE) reports into eight clinically relevant themes, including testing delays, diagnostic errors, pressure ulcers, and falls.

Toward zero harm: Mackenzie Health's journey toward becoming a high reliability organization and eliminating avoidable harm.

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Wilson M-A, Sinno M, Hacker Teper M, et al. J Patient Saf. 2022;18:680-685.

Achieving zero preventable harm is an ongoing goal for health systems. In this study, researchers developed a five-part strategy to achieve high-reliability and eliminate preventable harm at one regional health system in Canada – (1) engage leadership, (2) develop an organization-specific patient safety framework, (3) monitor specific quality aims (e.g., high-risk, high-cost areas), (4) standardize the incident review process, including the use of root cause analysis, and (5) communicate progress to staff in real-time via electronic dashboards. One-year post-implementation, researchers observed an increase in patient safety incident reporting and improvements in safety culture, as well as decreases in adverse events such as falls, pressure injuries and healthcare-acquired infections.

The Stoplight Mobility Alert System for safety and prevention of falls in children with physical and cognitive impairments.

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Patient Safety Innovation November 16, 2022

Patient falls are a never event and a frequent focus of patient safety and quality improvement projects. This pediatric ICU implemented a colored alert system based on fall risk assessments for all admitted 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.

Healthcare-associated adverse events in alternate level of care patients awaiting long-term care in hospital.

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Lim Fat GJ, Gopaul A, Pananos AD, et al. Geriatrics (Basel). 2022;7:81.

The risk of adverse events increases with prolonged hospital stays. This descriptive study examined adverse events among older patients with extended hospital admissions pending transfer to long-term care (LTC) settings at two Canadian hospitals. Analyses showed that patients were designated as “alternate level of care” (ALC) for an average of 56 days before transfer to LTC and adverse events such as falls and urinary tract infections were common.

Fall prevention with the Smart Socks System reduces hospital fall rates.

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Moore T, Kline D, Palettas M, et al. J Nurs Care Qual. 2023;38:55-60.

Fall prevention is a safety priority in hospital settings. This study found that Smart Socks – socks containing pressure sensors that detect when a patient is trying to stand up – reduced fall rates among patients at risk of falls in one hospital’s neurological and neurosurgical department. Over a 13-month period, investigators observed a decreased fall rate (0 per 1000 patient days) among patients wearing Smart Socks compared to prior to intervention implementation (4 per 1000 patient days).

The Nursing Home Expert Panel’s Falls Investigation Guide Toolkit: How-To Guide.

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Portland, OR: Oregon Patient Safety Commission; 2022.

Patient falls are common sentinel events. The latest revision of this toolkit shares insights on applying the tenets of root cause analysis to falls investigations.

Association between hospital acquired harm outcomes and membership in a national patient safety collaborative.

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Coffey M, Marino M, Lyren A, et al. JAMA Pediatr. 2022;176:924-932.

The Partnership for Patients (P4P) program launched hospital engagement networks (HEN) in 2011 to reduce hospital-acquired harms. This study reports on the outcomes of eight conditions from one HEN, Children's Hospitals' Solutions for Patient Safety (SPS). While the results do show a reduction in harms, the authors state earlier claims of improvement may have been overstated due to failure to not adjust for secular improvements. The co-director of Partnership for Patients, Dr. Paul McGann, was interviewed in 2016 for a PSNet perspective.

Adverse Health Events in Minnesota: Annual Reports.

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St Paul, MN: Minnesota Department of Health.

The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2021 report summarizes information about 508 adverse events that were reported, representing a significant increase in the year covered. Earlier reports document a fairly consistent count of adverse events. The rise reflected here is likely due to demands on staffing and care processes associated with COVID-19. Pressure ulcers and fall-related injuries were the most common incidents documented. Reports from previous years are available.

Developing and aligning a safety event taxonomy for inpatient psychiatry.

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Barnes T, Fontaine T, Bautista C, et al. J Patient Saf. 2022;18:e704-e713.

Patient safety event taxonomies provide a standardized framework for data classification and analysis. This taxonomy for inpatient psychiatric care was developed from existing literature, national standards, and content experts to align with the common formats used by the institution’s event reporting system. Four domains (provision of care, patient actions, environment/equipment, and safety culture) were identified, along with categories, subcategories, and subcategory details.

Optimizing post-acute care patient safety: a scoping review of multifactorial fall prevention interventions for older adults.

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Leland NE, Lekovitch C, Martínez J, et al. J Appl Gerontol. 2022;41:2187-2196.

Patient falls can be reduced through effective quality and safety strategies. This scoping review discusses common post-acute care intervention domains to reduce falls for older adults (e.g., staff education, individualized risk profiles) and study variability in the extent to which these domains are addressed.

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