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 92 Results

Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure.

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WebM&M Case February 1, 2023

A 5-day old male infant was admitted to the pediatric intensive care unit (PICU) and underwent surgery to correct a congenital heart defect. The patient’s postoperative course was complicated Staphylococcus aureus bacteremia and other problems, requiring venoarterial extracorporeal membrane oxygenation (VA-ECMO) and subsequent cardiac procedures.

Preventing medication errors in pediatric anesthesia: a systematic scoping review.

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Shawahna R, Jaber M, Jumaa E, et al. J Patient Saf. 2022;18:e1047-e1060.

Medication errors in pediatric anesthesiology are common and largely preventable. This scoping review characterizing medication errors in pediatric anesthesia found that dosing errors were the most common. Recommendations to minimize or prevent medication errors in pediatric anesthesia commonly related to improving medication administration and documentation.

Quality and Safety.

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Iyer R, Walker A, eds. Paediatr Anaesth. 2022;32(11):1176-1272.

Progress made in the adoption of infrastructure, Safety I, and Safety II concepts in high- and middle- to lower-income countries around the world support safe pediatric anesthesia care. The articles in this issue illustrate progress made over time in the specialty, highlight areas of focused attention, and examine quality improvement and Lean approaches as success strategies.

Standardization of pediatric noncardiac operating room to intensive care unit handoffs improves communication and patient care.

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Hebballi NB, Gupta VS, Sheppard K, et al. J Patient Saf. 2022;18:e1021-e1026.

Handoffs from one care team to another present significant risks to the patient if essential patient information is not shared or understood by all team members. Stakeholders at this children’s hospital developed a structured tool for handoff between surgery and pediatric or neonatal intensive care units. Transfer of information and select patient outcomes improved, handoff time was unchanged, and attendance by all team members increased.

To err is human, but what happens when surgeons err?

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Lin JS, Olutoye OO, Samora JB. J Pediatr Surg. 2023;58:496-502.

Clinicians involved in adverse events may experience feelings of guilt, shame, and inadequacy; this is referred to as “second victim” phenomenon. In this study of pediatric surgeons and surgical trainees, 84% experienced a poor patient outcome. Responses to the adverse event varied by level of experience (e.g., resident, attending), gender, and age.

Error traps in acute pain management in children.

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Vecchione TM, Agarwal R, Monitto CL. Paediatr Anaesth. 2022;32:982-992.

Appropriate pediatric pain management is an ongoing patient safety concern. This article discusses five categories of errors in pediatric acute pain management and how mitigating cognitive biases can help clinicians anticipate, identify, and avoid these errors.

Trial and error: learning from malpractice claims in childhood surgery.

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Prieto JM, Falcone B, Greenberg P, et al. J Surg Res. 2022;279:84-88.

Hospitalized children are vulnerable to patient safety risks. Using a large malpractice claims database, researchers found that a wide range of pediatric surgical specialties – including orthopedics, general surgery, and otolaryngology – are most frequently associated with malpractice lawsuits. The study identified several potentially modifiable factors (i.e., patient evaluations, technical performance, and communication) that can lead to improvements in pediatric surgical safety.

Incidence and characteristics of errors detected by a short team briefing in pediatric anesthesia.

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Keil O, Brunsmann K, Boethig D, et al. Paediatr Anaesth. 2022;32:1144-1150.

Harm from pediatric anesthesia-related errors is infrequent, but largely preventable. This pediatric hospital developed and implemented an anesthesia-specific checklist to be used before anesthesia induction. This study presents the types of errors identified by the checklist over the course of one year.

Adverse events in infants less than 6 months of age after ambulatory surgery and diagnostic imaging requiring anesthesia.

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Uffman JC, Kim SS, Quan LN, et al. Pediatr Qual Saf. 2022;7:e574.

Pediatric patients are highly vulnerable to patient safety events in the hospital. This retrospective study of infants less than 6 months of age admitted for ambulatory surgery found that the recommended 2-hour postoperative monitoring did not affect patient safety.

Pediatric surgical errors: a systematic scoping review.

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Marsh KM, Fleming MA, Turrentine FE, et al. J Pediatr Surg. 2022;57:616-621.

Patient safety improvement can be hindered by lack of effective measurement tools. This scoping review explored how medical errors are defined and measured in studies of pediatric surgery patients. The authors identified several evidence gaps, including absence of standardized error definitions.

Implicit racial bias in pediatric orthopaedic surgery.

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Guzek R, Goodbody CM, Jia L, et al. J Pediatr Orthop. 2022;42:393-399.

Research has demonstrated inequitable treatment of racially minoritized patients resulting in poorer health outcomes. This study aimed to determine if implicit racial bias impacts pediatric orthopedic surgeons’ clinical decision making. While pediatric orthopedic surgeons showed stronger pro-white implicit bias compared to the US general population (29% vs. 19%), the bias did not appear to affect decision making in clinical vignettes.

Intraosseous Line Extravasation in a Pediatric Trauma Patient

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WebM&M Case April 27, 2022

An 18-month-old girl presented to the Emergency Department (ED) after being attacked by a dog and sustaining multiple penetrating injuries to her head and neck. After multiple unsuccessful attempts to establish intravenous access, an intraosseous (IO) line was placed in the patient’s proximal left tibia to facilitate administration of fluids, blood products, vasopressors, and antibiotics. In the operating room, peripheral intravenous (IV) access was eventually obtained after which intraoperative use of the IO line was restricted to a low-rate fluid infusion.

Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest

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WebM&M Case January 26, 2022

This case involves a 2-year-old girl with acute myelogenous leukemia and thrombocytopenia (platelet count 26,000 per microliter) who underwent implantation of a central venous catheter with a subcutaneous port. The anesthetist asked the surgeon to order a platelet transfusion to increase the child’s platelet count to above 50,000 per microliter. In the post-anesthesia care unit, the patient’s arterial blood pressure started fluctuating and she developed cardiac arrest.

Pediatric medication errors and reduction strategies in the perioperative period.

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Bekes JL, Sackash CR, Voss AL, et al. AANA J. 2021;89(4):319-324.

Pediatric medication errors during anesthesia can lead to significant harm and are largely preventable. This review identifies several themes around medication errors including dosing and incorrect medication. Successful error reduction strategies, such as standardized labeling and pre-filled syringes, are also described.

The Hidden Danger of Unseen Intravenous Catheters

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WebM&M Case October 27, 2021

A 6-week-old infant underwent a craniotomy and excision of abnormal brain tissue for treatment of hemimegalencephaly and epilepsy.

Opioid prescribing to US children and young adults in 2019.

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Chua K-P, Brummett CM, Conti RM, et al. Pediatrics. 2021;148:e2021051539.

Despite public policies and guidelines to reduce opioid prescribing, providers continue to overprescribe these medications to children, adolescents, and young adults. In this analysis of US retail pharmacy data, 3.5% of US children and young adults were dispensed at least one opioid prescription; nearly half of those included at least one factor indicating they were high risk. Consistent with prior research, dentists and surgeons were the most frequent prescribers, writing 61% of all opiate prescriptions.

Reducing surgical specimen errors through multidisciplinary quality improvement.

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Holstine JB, Samora JB. Jt Comm J Qual Patient Saf. 2021;47:563-571.

Errors in surgical specimen handling can cause treatment delays or missed diagnoses. This children’s hospital implemented a quality improvement effort to reduce surgical specimen errors. Using a variety of methods, including changes to specimen labeling, improved communication, and specimen time-out, they were able to decrease the mean rate of order errors and labeling-related errors.

Timeout procedure in paediatric surgery: effective tool or lip service? A randomised prospective observational study.

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Muensterer OJ, Kreutz H, Poplawski A, et al. BMJ Qual Saf. 2021;30:622-627.

Preoperative checklists and timeouts are common tools to improve patient safety. Over a 16-month period, this study purposefully and randomly introduced errors during preoperative timeouts for 1,800 procedures but only 54% of these errors were reported by operating team members. The authors suggest that future research should explore ways to improve the quality of surgical timeouts to reduce risks to patient safety.

Supporting recovery after adverse events: an essential component of surgeon well-being.

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Berman L, Rialon KL, Mueller CM, et al. J Pediatr Surg. 2021;56:833-838.

Clinicians who are involved in an adverse even often experience emotional and psychological distress afterwards. A survey found that 80% of responding pediatric surgeons had personally experienced a medical error resulting in significant patient harm or death. Only one-quarter of those respondents were satisfied with the institutional support they received afterwards. Respondents cited numerous barriers (lack of trust, blame, shame) to receiving support.

Outcomes from Wake Up Safe, the pediatric anesthesia quality improvement initiative.

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Haché M, Sun LS, Gadi G, et al. Paediatr Anaesth. 2020;30:1348-1354.

The Wake Up Safe initiative includes a registry of serious adverse events occurring in pediatric anesthesia. This study analyzed events reported between 2010 and 2015. The most common anesthesia-related events were medication events, respiratory complications, and cardiac events. Approximately 85% of these events were considered to be preventable.

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