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.
de Loizaga SR, Clarke-Myers K, R Khoury P, et al. J Patient Exp. 2022;9:237437352211026.
Parents have reported the importance of being involved in discussions with clinicians following adverse events involving their children. This study asked parents and physicians about their perspectives on inclusion of parents in morbidity and mortality (M&M) reviews. Similar to earlier studies, parents wished to be involved, while physicians were concerned that parent involvement would draw attention away from the overall purpose (e.g., quality improvement) of M&M conferences.
Sugrue A, Sanborn D, Amin M, et al. Am J Cardiol. 2020;144:52-59.
Anticoagulants are common medications that carry the potential for serious harm if administered incorrectly. This retrospective review of 8,576 patients with atrial fibrillation who received direct oral anticoagulants identified inappropriate dosing in nearly 15% of cases, with most patients receiving an inappropriately low dose. Over one year of follow-up, the authors did not identify any significant difference in the incidence of stroke, embolism, bleeding, or ischemic attacks between patients who were inappropriately, versus appropriately, dosed.
Wolfe HA, Wenger J, Sutton RM, et al. Pediatr Qual Saf. 2020;59:e319.
This article describes the use of “cold” debriefings performed more than one day after in-hospital cardiac arrest events at institutions participating in a pediatric resuscitation quality collaborative. Cold debriefings took place in one-third of events; the median time to debriefing was 26 days. The majority of comments arising from the debriefings involved clinical standards, cooperation and communication.
Pater CM, Sosa TK, Boyer J, et al. BMJ Qual Saf. 2020;29:717-726.
Continuous vital sign monitoring can generate a large volume of alarm notifications that may not represent meaningful change in clinical status and can lead to alarm fatigue, which has become a patient safety priority. This article describes Plan-Do-Study-Act processes employed in the acute care cardiology unit of a large, urban academic medical center that resulted in a reduction in alarm notifications of 68% over 2.5 years. Patient safety was maintained as these improvements were made and reductions in alarm notifications were sustained for more than 18 months.
Pediatric cardiac surgery is highly technical and risky. This newspaper article reports on a poorly performing pediatric cardiac surgery program, concerns raised by staff, and insufficient response from organizational leadership. Lack of data transparency, insufficient resources, and limited program capabilities to support a complex program contributed to poor outcomes for pediatric patients.
In this retrospective study, researchers found that the diagnosis of systolic heart failure had been missed on first presentation for almost 50% of pediatric patients hospitalized with new-onset heart failure. Incorrect diagnostic labels frequently assigned to these patients included bacterial infection, viral illness, and gastroenteritis.
McGrory K, Bedi N. Tampa Bay Times. November 28, 2018.
Pediatric cardiac surgery is a high-risk practice. This news investigation reports on a series of serious patient safety incidents at a health care institute dedicated to treating heart problems in children and the cultural and individual provider issues that perpetuate unsafe care.
Researchers surveyed pediatric cardiac intensive care unit providers across three tertiary cardiac centers in the United States. More than 80% of respondents perceived diagnostic errors to be common and 65% reported errors causing permanent harm to patients. Improving feedback and teamwork were frequently suggested as strategies for reducing diagnostic error.
Hansen M, Eriksson C, Skarica B, et al. Am J Emerg Med. 2018;36:380-383.
Adverse events in prehospital care are an increasing area of focus in patient safety. In this retrospective study, researchers examined the medical records of 35 out-of-hospital cardiac arrests among children younger than 18 transported by a single emergency medical services system. They identified a safety issue in 87% of cases and, similar to prior research, they found that medication errors were common.
Su L. Curr Probl Pediatr Adolesc Health Care. 2015;45:367-9.
Efforts to understand the nature of human error can enhance care safety. Discussing the potential for unexpected human behaviors during crises to result in failure, this commentary reveals how insights drawn from video analysis of teams in critical situations informed adjustments to training to reduce risks in cardiac care.
Admitted to the hospital with sepsis and pneumonia, an elderly man developed acute respiratory distress syndrome requiring mechanical ventilation. On hospital day 12, clinicians placed a tracheostomy, and a few days later the patient developed acute hypoxia and ultimately went into cardiac arrest when his tracheostomy tube became dislodged.
A 21-year-old woman with a history of Marfan syndrome complicated by aortic root dilation presented to the emergency department with abdominal pain and was found to be pregnant. It was her second pregnancy; she had a therapeutic abortion 4 years earlier due to the risk of aortic rupture during pregnancy. At that time, the patient had been advised to have her aortic root surgically repaired in the near future. However, after the patient turned 18, she did not receive regular follow-up care or pre-conception or contraception counseling despite the risk to her health should she become pregnant.
Hickey EJ, Nosikova Y, Pham-Hung E, et al. J Thorac Cardiovasc Surg. 2015;149:496-505; discussion 505-7.
In this study, the National Aeronautics and Space Administration's error detection model was used to analyze the incidence and types of error in pediatric cardiac surgery procedures. The investigators found that errors occurred in nearly half of all operations and frequently manifested as cycles of error whereby the effect of a single error was compounded by failure to rescue.
Bowermaster R, Miller M, Ashcraft T, et al. J Am Coll Surg. 2015;220:149-55.e3.
This observational study describes how a pediatric cardiac surgery team used the human factors approach of recording even small deviations from ideal practice in order to better characterize safety problems. The authors describe how systematically capturing small failures led to recognition of faulty processes that could be addressed. A recent AHRQ WebM&M commentary discusses the application of human factors engineering to enhance safety of medical device design.
Lammers RL, Willoughby-Byrwa M, Fales WD. Simul Healthc. 2014;9:174-183.
Simulations of prehospital pediatric cardiopulmonary arrest uncovered many potential errors. Most notably, medication errors related to the correct weight-based dosing of epinephrine were common. This mistake can have serious consequences and warrants further efforts to mitigate this risk.
Residents and nurses assumed an ICU attending was conveying information to the surgeon and cardiologist about a toddler's deteriorating condition after heart surgery. However, none of the providers had a complete picture of the child's status, and he suffered a cardiac arrest.
Hill AC, Miyake CY, Grady S, et al. J Pediatr. 2011;159:783-8.
Controversy exists regarding whether children should be required to undergo an electrocardiogram before participating in competitive sports. This study found a significant rate of diagnostic error among pediatric cardiologists in the interpretation of abnormal screening electrocardiograms.
An adolescent girl passed out after a soccer game, and her father, a physician, took her to the pediatrician for tests. The physician father obtained a copy of his daughter’s ECG, panicked because it was not normal, and began guiding his daughter’s medical care.
Wang GS, Erwin N, Zuk J, et al. J Hosp Med. 2011;6:131-5.
This study found that 39% of emergency response activations occurred in children younger than age 1 year, with the most common admission diagnosis related to cardiac disease. The authors suggest that young children with known comorbidities may benefit from more deliberate patient planning, placement, staffing, and early ICU intervention.
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