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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 185 Results
Hose B-Z, Carayon P, Hoonakker PLT, et al. Appl Ergon. 2023;113:104105.
Health information technology (IT) usability continues to be a source of patient harm. This study describes the perspectives of a variety of pediatric trauma team members (e.g., pediatric emergency medicine attending, surgical technician, pediatric intensive care unit attending) on the usability of a potential team health IT care transition tool. Numerous barriers and facilitators were identified and varied across department and role.
Michelson KA, Bachur RG, Grubenhoff JA, et al. J Emerg Med. 2023;65:e9-e18.
Missed diagnosis in the emergency department can result in unplanned hospitalization due to complications from worsening symptoms. In this study, pediatric patients with and without missed emergency department diagnosis were compared to determine differences in outcomes and hospital utilization. Children with missed diagnosis of appendicitis or new-onset diabetic ketoacidosis experienced more complications, hospital days and readmissions; there was no difference for sepsis diagnosis.
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.
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.
Michelson KA, McGarghan FLE, Patterson EE, et al. Diagnosis (Berl). 2023;10:183-186.
Delayed diagnosis of appendicitis can lead to serious patient harm. This study of 7,452 pediatric patients with appendicitis found that delayed diagnosis occurred in 1.4% of cases and increased clinician use of blood tests decreased the likelihood of delayed diagnosis.
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.
Yang CJ, Saggar V, Seneviratne N, et al. Jt Comm J Qual Patient Saf. 2023;49:297-305.
Simulation training is commonly used by hospitals to identify threats to safety and improve patient care. This article describes the development and implementation of an in situ simulation to improve acute airway management during the COVID-19 pandemic across five emergency departments. The simulation protocol helped identify latent safety threats involving equipment, infection control, and communication. The simulation process also helped staff identify interventions to reduce latent safety threats, including improved accessibility of airway management equipment, a designated infection control cart, and role identification cards to improve team function.
Kelen GD, Kaji AH, Schreyer KE, et al. Ann Emerg Med. 2023;82:336-340.
In December 2022, AHRQ released Diagnostic Errors in the Emergency Department: a Systematic Review which received extensive coverage in both academic publications and the national media. This peer-reviewed commentary asserts emergency department (ED) overcrowding is a greater safety risk than misdiagnosis, and errors are more frequently systemic rather than cognitive.
Wolf MS, Smith K, Basu M, et al. J Pediatr Intensive Care. 2023;12:125-130.
Preventable harm continues to occur in high-risk care environments such as the pediatric intensive care unit (ICU). In this survey of 266 clinicians within a large pediatric healthcare system, 42% reported experiencing psychological distress after an adverse event, 22% reported absenteeism and 23% reported considering leaving the ICU. After involvement in an adverse event, respondents said that they would prefer peer support and the ability to step away from the unit to recover.
Petrino R, Tuunainen E, Bruzzone G, et al. Eur J Emerg Med. 2023;30:280-286.
The emergency department is a busy and complex environment that can present challenges to patient safety. This survey of emergency medicine professionals from 101 countries identified several patient safety concerns, including workflow and staffing, overcrowding and perceived lack of leadership support. Two PSNet WebM&M commentaries highlight the impact of boarding and overcrowding in the emergency department on patients with a postoperative infection and ruptured abdominal aortic aneurysm.
Yanni E, Calaman S, Wiener E, et al. J Healthc Qual. 2023;45:140-147.
I-PASS is a structured handoff tool that aims to improve communication and reduce adverse events during transitions of care. This article describes the implementation of a modified I-PASS tool for use in the emergency department (ED I-PASS) to improve transitions of care between pediatric emergency medicine physicians. Implementation of ED I-PASS decreased the perceived loss of key patient information during transitions of care (from 75% to 37.5%).
Rainer T, Lim JK, He Y, et al. Hosp Pediatr. 2023;13:461-470.
Structural racism and implicit biases can affect clinical judgement and impede the delivery of effective mental health care. Based on a case of an adolescent Black girl navigating through the pediatric behavioral health system, this article discusses how structural racism and health disparities in behavioral health care contributed to misdiagnosis and poor care. The authors outline several actions at the structural, institutional, and interpersonal levels to address racism’s impact on pediatric mental and behavioral healthcare.

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

Misattribution of child maltreatment injuries can be a serious misdiagnosis affecting families and patients. This report analyzes ten safety incident reports from across the British National Health Service to explore how non-accidental injury was missed. Themes identified as contributing to the problems include lack of information sharing, inconsistent guidance, and emergency department care demands.
Mahajan P, Grubenhoff JA, Cranford J, et al. BMJ Open Qual. 2023;12:e002062.
Missed diagnostic opportunities often involve multiple process breakdowns and can lead to serious avoidable patient harm. Based on a web-based survey of 1,594 emergency medicine physicians, missed diagnostic opportunities most frequently occur in children who present to the emergency department with undifferentiated symptoms (e.g., abdominal pain, fever, vomiting) and often involve issues related to the patient/parent-provider interaction, such as misinterpreting patient history or inadequate physical exam.
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.
WebM&M Case April 26, 2023

This case involves a procedural sedation error in a 3-year-old patient who presented to the Emergency Department with a left posterior hip dislocation. The commentary summarizes the indications and risks of procedural sedation in non-surgical settings and highlights the value of implementing system-wide safety protocols and practices to prevent medication administration errors during high-risk procedures.

Gross TK, Lane NE, Timm NL, et al. Pediatrics. 2023;151:e2022060971-e2022060972.
Emergency room crowding is a persistent factor that degrades safety for patients of all ages. This collection provides background, best practices, and recommendations to reduce emergency department crowding and its negative impact on pediatric care. The publications examine factors that influence crowding and improvement at the input, departmental, and hospital/outpatient stages of emergency care.

Derfel A. Montreal Gazette. February 24- March 1, 2023

Emergency room failures are often rooted in system weaknesses. This series examines six patient deaths associated with emergency care that, while concerns were raised by nursing staff, have not been explored to initiate improvements at the facility. Factors contributing to the deaths discussed include nurse shortages, inconsistent oversight, and poor training.
Liberman AL, Holl JL, Romo E, et al. Acad Emerg Med. 2022;30:187-195.
A missed or delayed diagnosis of stroke places patients at risk of permanent disability or death. This article describes how interdisciplinary teams used a failure modes, effects, and criticality analysis (FMECA) to create an acute stroke diagnostic process map, identify failures, and highlight existing safeguards. The FMECA process identified several steps in the diagnostic process as the most critical failures to address, including failure to screen patients for stroke soon after presentation to the Emergency Department (ED), failure to obtain an accurate history, and failure to consider a stroke diagnosis during triage.
Jafri FN, Yang CJ, Kumar A, et al. Simul Healthc. 2023;18:16-23.
In situ simulation is a valuable way to uncover latent safety threats (LTS) when implementing new workflows or care locations. This study reports on one New York state emergency department’s in situ simulation of airway control for COVID-19 patients. Across three cycles of Plan-Do-Study-Act, numerous LSTs were identified and resolved. Quarterly airway management simulations have continued and have expanded to additional departments and conditions, suggesting the sustainability of this type of quality improvement project.