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 147 Results

A scoping review exploring the confidence of healthcare professionals in assessing all skin tones.

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Harrison J. Br Paramed J. 2023;8:18-28.

Patients with dark skin tones are not well represented in health education, particularly dermatology, which can result in delayed diagnosis. In this scoping review, thirteen articles were identified assessing the confidence of students and healthcare providers in assessing patients with dark skin tones. Overall, confidence was low but tailored training somewhat improved confidence. The author asserts more research and education is needed outside dermatology, for example, when assessments use terms such as pale, redness, or blue.

Understanding And Addressing Pre-Hospital Diagnostic Delays.

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Health Affairs Forefront; May-September 2023.

Diagnostic delays stem from both human and process failures. This series of articles examines how strategies such as behavioral design, internet use, and prehospital practice play a role in the timing of diagnosis.

Weight estimation for drug dose calculations in the prehospital setting - a systematic review.

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Wells M, Henry B, Goldstein L. Prehosp Disaster Med. 2023;38:471-484.

Inaccurate estimations of patient weight can lead to medication errors in the prehospital period. This systematic review of 9 studies concluded that there is insufficient evidence to assess the accuracy of weight estimation approaches used in the EMS setting or by paramedics, underscoring the need for additional, robust research in this area.

Harm Caused by Delays in Transferring Patients to the Right Place of Care.

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Farnborough, UK: Healthcare Safety Investigation Branch; August 2023.

Handoffs between prehospital emergency medical services (EMS) providers and hospital emergency departments (EDs) can be suboptimal, which increases patient harm potential. This report examines National Health Service discharge delays. It suggests a systemic approach is needed to address flow and capacity factors that contribute to ineffective and unsafe interfacility discharge and transfer.

Women with large vessel occlusion acute ischemic stroke are less likely to be routed to comprehensive stroke centers.

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Tariq MB, Ali I, Salazar‐Marioni S, et al. J Am Heart Assoc. 2023;12:e029830.

Delayed diagnosis and treatment of stroke leads to adverse patient outcomes. This cross-sectional study identified gender disparities in the treatment of patients with large vessel occlusion (LVO) acute ischemic stroke (AIS), with women being less likely to be routed directly to comprehensive stroke centers compared with men, despite having more significant stroke syndromes.

Improving emergency medicine clinician awareness of prehospital-administered medications.

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Kamta J, Fregoso B, Lee A, et al. Prehosp Emerg Care. 2023;Epub Jul 28.

Handoffs from emergency medical services (EMS) to the emergency department (ED) are vulnerable to communication errors due to the time-pressured environment. This study reports on the implementation of an electronic health record (EHR) tool that added pre-hospital medication administration to the ED triage note to reduce medication administration errors (MAE). Although most ED providers reported they "always" review the triage note, MAE rates did not improve following implementation.

Factors influencing the perception of feeling safe in pre-hospital emergency care: a mixed-methods systematic review.

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Péculo‐Carrasco J‐A, Luque‐Hernández MJ, Rodríguez‐Ruiz H‐J, et al. J Clin Nurs. 2023;32:4473-4491.

Emergency medical services (EMS) and pre-hospital care present unique challenges to ensure the delivery of safe care. This systematic review, including both qualitative and quantitative studies, identified four dimensions influencing patient perceptions of safety in pre-hospital care – satisfactory response from the emergency medical system, competence of EMS personnel, the setting of care/environmental factors, and patients’ personal characteristics.

Emergency lights and sirens on ambulances may do more harm than good.

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Renault M. Stat. July 7, 2023.

Emergency vehicle transport can be dangerous for the patient, the clinician team, and the community. This article discusses the effect of ambulance use of alarm sirens on the safety of the service. Impacts such as psychological health of the patient and access to care units, should a crash occur, are discussed.

Types and effects of feedback for emergency ambulance staff: a systematic mixed studies review and meta-analysis.

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Wilson C, Janes G, Lawton R, et al. BMJ Qual Saf. 2023;32:573-588.

Feedback interventions (e.g., debriefing, peer-to-peer, audit, and feedback) can encourage learning from safety events and improve quality of care. This systematic review of 48 studies found that providing feedback to emergency medical services (EMS) personnel can improve documentation and adherence to protocols, with some studies also documenting improvements in clinical decision-making and cardiac arrest performance.

Finnish emergency medical services managers' and medical directors' perceptions of collaborating with patients concerning patient safety issues: a qualitative study.

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Venesoja A, Tella S, Castrén M, et al. BMJ Open. 2023;13:e067754.

Emergency medical services (EMS) personnel encounter unique safety challenges when delivering patient care. Using focus groups and individual interviews with EMS medical directors and managers in Finland, this qualitative study explored perceptions around patient collaboration to improve safety in EMS. Participants agreed that patient safety is an organizational responsibility and management should provide EMS patients with opportunities to speak up as well as address barriers to voicing concerns.

Interorganizational health information exchange-related patient safety incidents: a descriptive register-based qualitative study.

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Hyvämäki P, Sneck S, Meriläinen M, et al. Int J Med Inform. 2023;174:105045.

Insufficient or incorrect transfer of patient information, whether caused by human or organizational factors, can result in adverse events during transitions of care. This study used four years of incident reports to identify the types, causes, and consequences of health information exchange- (HIE) related patient safety incidents in emergency care, (ED) emergency medical services (EMS), or home care. The two main kinds of HIE-related incidents were (1) inadequate documentation and inadequate use of information (e.g., deficiencies in content), and (2) causes related to the health professional or organization; consequences were adverse events or additional actions to prevent, avoid, and correct adverse events.

The effect of documenting patient weight in kilograms on pediatric medication dosing errors in emergency medical services.

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Ward CE, Taylor M, Keeney C, et al. Prehosp Emerg Care. 2023;27:263-268.

Weight-based calculation errors and lack of weight documentation can lead to medication errors in pediatric patients. This analysis of Maryland emergency medical services (EMS) data including children who received a weight-based medication found that weight documentation was associated with a small but significantly lower rate of medication dose errors, particularly among infants and for epinephrine and fentanyl doses.

NHS staff cried in safety interviews, says watchdog.

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Reed J. BBC. February 27, 2023.

Stressful and caustic work environments are known to compromise health care safety and teamwork. This news story discusses an ongoing investigation in the British National Health Service to examine factors in ambulance services that minimize its safety and effectiveness. Clinicians interviewed revealed serious problems with the work cultures.

An analysis of prehospital pediatric medication dosing errors after implementation of a state-wide EMS pediatric drug dosing reference.

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Kazi R, Hoyle JD, Huffman C, et al. Prehosp Emerg Care. 2023;Epub Feb 1.

Prehospital medication administration for pediatric patients is complicated by the need to obtain an accurate weight for correct dosing. This retrospective analysis examined prehospital medication dosing in children 12 years of age and younger after implementation of a statewide emergency medical services (EMS) pediatric dosing reference. Despite implementation of written guidelines, researchers found that 35% of prehospital medication administrations involved a dosing error. Dosing errors were most common for hyperglycemia reversal medications, opioids, and one type of bronchodilator (Ipratropium bromide).

'They were his best shot. And they failed to help’: why did EMS workers neglect Tyre Nichols?

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Renault M. STAT. February 6, 2023.

Emergent care situations are vulnerable to a range of factors that reduce care safety and access. This article examines safety culture, implicit biases, and system issues that impacted access to needed emergency care for a patient involved in a police action.

Self-assessment and learning motivation in the second victim phenomenon.

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Bushuven S, Trifunovic-Koenig M, Bentele M, et al. Int J Environ Res Public Health. 2022;19:16016.

Healthcare workers (HCWs) who are involved in serious adverse events may feel traumatized by those events, and many organizations have implemented “second victim” training programs to support their workers. This study sought to understand HCWs’ motivations to attend such trainings and a potential association with overconfidence. Understanding the association may help organizations develop effective training programs and increase motivation to attend them.

Strategies for a safe interhospital transfer with an intubated patient or where readiness for intubation is needed: a critical incidents study.

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Almqvist D, Norberg D, Larsson F, et al. Intensive Crit Care Nurs. 2022;74:103330.

Interhospital transfers pose a serious risk to patients. In this study, nurse anesthetists and intensive care nurses described strategies to ensure safe transport for patients who are intubated or who may require intubation. Strategies include clear and adequate communication between providers prior to transport, stabilizing and optimizing the patient’s condition, and ensuring that appropriate drugs and equipment are prepared and available.

A novel study of situational awareness among out-of-hospital providers during an online clinical simulation.

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Hunter J, Porter M, Williams B. Australas Emerg Care. 2023;26:96-103.

Situational awareness (SA) requires recognizing situations, interpreting them, and predicting how the situation may unfold in the future. Paramedics and emergency medical technicians (EMT) participated in a video simulation to assess their SA at each of the three stages. Quantitative results indicated the providers were not situationally aware during the simulation.

EMS Perils from Hospital Overcrowding

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WebM&M Case August 31, 2022

A 71-year-old man presented to a hospital-based orthopedic surgery clinic for a follow-up evaluation of his knee and complaints of pain and swelling in his right shoulder. His shoulder joint was found to be acutely inflamed and purulent fluid was aspirated from his shoulder. The patient was sent to the Emergency Department (ED) for suspected septic arthritis.

Miscommunication During the Interhospital Transport of a Critically Ill Child

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WebM&M Case August 31, 2022

A 2-year-old girl presented to her pediatrician with a cough, runny nose, low grade fever and fatigue; a nasal swab for SARS-CoV-2 and influenza was negative and lung sounds were clear. The patient developed a fever and labored breathing and was taken to the Emergency Department (ED) before being admitted to the hospital. She developed respiratory distress and clinically worsened over time until she developed respiratory failure requiring air transportation to the pediatric intensive care unit at a children’s hospital.

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