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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 138 Results
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.
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.

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.
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).
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.
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.
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.
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.

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.

Kosydar-Bochenek J, Krupa S, Religa D, et al. Int J Environ Res Public Health. 2022;19:9712.
A positive safety climate can improve patient safety and worker wellbeing. The Safety Attitudes Questionnaire (SAQ) was distributed to physicians, nurses, and paramedics in five European countries to assess and compare safety climate between professional roles, countries, and years of healthcare experience. All three groups showed positive attitudes towards patient safety, stress recognition, and job satisfaction; however, overall scores were low.
Walker D, Moloney C, SueSee B, et al. Prehosp Emerg Care. 2022;Epub Jun 27.
Safe medication management practices are critical to providing safe care in all healthcare settings. While there are studies reporting a variety of prehospital adverse events (e.g., respiratory and airway events, communication, etc.), there have been few studies of medication errors that occur in prehospital settings. This mixed methods systematic review of 56 studies and case reports identifies seven major themes such as organizational factors, equipment/medications, environmental factors, procedure-related factors, communication, patient-related factors, and cognitive factors as contributing to safe medication management.
Hoff JJ, Zimmerman A, Tupetz A, et al. Prehosp Emerg Care. 2023;27:418-426.
Involvement in serious adverse events can cause clinicians to feel significant and ongoing emotional trauma. Interviews with eight emergency medical service (EMS) personnel revealed self-perceived errors were more likely to result in feelings of shame, and a positive safety culture supported recovery and resilience.

Farnborough, UK: Healthcare Safety Investigation Branch; June 2022.

Handoffs between prehospital emergency medical services (EMS) providers and hospital emergency departments (EDs) can be suboptimal, which increases patient harm potential. This interim 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.
Hunter J, Porter M, Cody P, et al. Int Emerg Nurs. 2022;63:101174.
Many aspects of crew resource management in aviation, such as the sterile cockpit, are used in healthcare to increase situational awareness (SA) and decrease human error. The situational awareness of paramedics in one US city was measured before and after receiving a targeted educational program on situational awareness. There was a statistically significant increase in SA following the intervention, although additional research is needed with larger cohorts.
Johansson H, Lundgren K, Hagiwara MA. BMC Emerg Med. 2022;22:79.
Emergency medical services (EMS) clinicians must decide whether to transport patients to hospitals for emergency care, what level of emergency care they require, or to treat the patient at home and not transport to hospital. This analysis focused on patient safety incidents in Swedish prehospital care that occurred after 2015, following implementation of a protocol allowing EMS clinicians to triage patients to see-and-treat (non-conveyance) or see-and-convey elsewhere. Qualitative analysis of incident reports revealed three themes: assessment of patients, guidelines, and environment and organization. EMS clinicians deviated from the protocol in 34% of cases, putting patients at risk of inappropriate triage to see-and-treat.
Buitrago I, Seidl KL, Gingold DB, et al. J Healthc Qual. 2022;44:169-177.
Reducing hospital 30-day readmissions is seen as a way to improve safety and reduce costs. Baltimore City mobile integrated health and community paramedicine (MIH-CP) was designed to improve transitional care from hospital to home. After one year in operation, MIH-CP performed a chart review to determine causes of readmission among patients in the program. Root cause analysis indicated that at least one social determinant of health (e.g., health literacy) played a role in preventable readmissions; the program was modified to improve transitional care.
Tate K, McLane P, Reid C, et al. BMJ Open Qual. 2022;11:e001639.
Older adults are vulnerable to patient safety events during care transitions. The Older Persons’ Transitions in Care (OPTIC) study prospectively tracked long-term care residents’ transitions and applied the IOM’s quality of care domains to develop 49 measures for quality of care for the transition process (e.g., safety, timeliness, efficiency, effectiveness, and patient-centered care) between long-term care and emergency department settings.
WebM&M Case May 16, 2022

This WebM&M describes two incidences of the incorrect patient being transported from the Emergency Department (ED) to other parts of the hospital for tests or procedures. In one case, the wrong patient was identified before undergoing an unnecessary procedure; in the second case, the wrong patient received an unnecessary chest x-ray. The commentary highlights the consequences of patient transport errors and strategies to enhance the safety of patient transport and prevent transport-related errors.

Saleem J, Sarma D, Wright H, et al. J Patient Saf. 2022;18:152-160.
Hospitals employ a variety of strategies to prevent inpatient falls. Based on data from incident reports, this study used process mapping to identify opportunities to improve timely diagnosis of serious injury resulting from inpatient falls. Researchers found that multiple interventions (e.g., education, changes in the transport process) with small individual effects resulted in a substantial cumulative positive impact on delays in the diagnosis of serious harm resulting from a fall.