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 - 17 of 17 Results

Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture.

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WebM&M Case June 28, 2023

A 56-year-old man was admitted to the hospital and required mechanical ventilation due to COVID-19-related pneumonia and acute respiratory failure. The care team performed a tracheostomy percutaneously at the bedside with some difficulty. The tracheostomy tube was secured, inspected via bronchoscopy, and properly sutured. During the next few days, the respiratory therapist noticed a leak that required additional inflation of the cuff to maintain an adequate seal.

The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department.

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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.

The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis

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Patient Safety Innovation March 15, 2023

During a time of unprecedented patient volume and clinical uncertainty, a diverse team of health system administrators and clinicians within the University of Pennsylvania Health System quickly investigated, updated, and disseminated airway management protocols after several airway safety incidents occurred among COVID-19 patients who were mechanically ventilated. Based on this experience, the team created the I-READI framework as a guide for healthcare systems to prepare for and quickly respond to quality and safety crises.¹

In situ simulation as a tool to longitudinally identify and track latent safety threats in a structured quality improvement initiative for SARS-CoV-2 airway management: a single-center study.

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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.

EMS crews brought patients to the hospital with misplaced breathing tubes. None of them survived

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Arditi L. Peoples Public Radio. December 3, 2019.

Emergency medical services are often provided under chaotic circumstances that may contribute to failure. This story highlights a series of esophageal intubation errors and efforts to minimize this “never event” across the state of Rhode Island. Improvement strategies discussed include practice restrictions for EMT personnel and use of less invasive, less risky processes to provide oxygen as an alternative to intubation, which may reduce esophageal intubation errors

Reducing three infections across cardiac surgery programs: a multisite cross-unit collaboration.

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Chang BH, Hsu Y-J, Rosen MA, et al. Am J Med Qual. 2020;35:37-45.

Preventing health care–associated infections remains a patient safety priority. This multisite study compared rates of central line–associated bloodstream infections, surgical site infections, and ventilator-associated pneumonia before and after implementation of a multifaceted intervention. Investigators adopted the comprehensive unit-based safety program, which emphasizes safety culture and includes staff education, identification of safety risks, leadership engagement, and team training. Central line–associated bloodstream infections and surgical site infections initially declined, but rates returned to baseline in the third year. They were unable to measure differences in ventilator-associated pneumonia rates due to a change in the definition. These results demonstrate the challenge of implementing and sustaining evidence-based safety practices in real-world clinical settings. A past PSNet interview discussed infection prevention and patient safety.

Association between night-time surgery and occurrence of intraoperative adverse events and postoperative pulmonary complications.

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Cortegiani A, Gregoretti C, Neto AS, et al; LAS VEGAS Investigators, PROVE Network, Clinical Trial Network of the European Society of Anaesthesiology. Br J Anaesth. 2019;122:361-369.

This study found that patients undergoing surgery at night were more likely to develop intraoperative adverse events, even after adjustment for patient and procedural characteristics. The observed increase in postoperative pulmonary complications was explained by the type of surgery and underlying patient characteristics. This study adds to the body of evidence on risks associated with care outside of usual working hours.

Office-based surgery and patient outcomes.

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Young S, Shapiro FE, Urman RD. Curr Opin Anaesthesiol. 2018;31:707-712.

Office-based surgery is increasingly common, despite concerns regarding its safety. This review summarizes the literature on ambulatory surgery outcomes and identified risk factors such as case complexity, patient comorbidities, and anesthesia use. Few studies examined anesthesia use in dental care.

Implementing strategies to identify and mitigate adverse safety events: a case study with unplanned extubations.

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Hatch D, Rivard M, Bolton J, et al. Jt Comm J Qual Patient Saf. 2019;45:295-303.

The authors describe how the use of statistical process control charts facilitated rapid identification of a cluster of unplanned extubations in a neonatal intensive care unit. They advocate for the use of continuous monitoring tools to help alert teams to possible safety events and improvement opportunities.

Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator for Postoperative Respiratory Failure (PSI 11) does not identify accurately patients who received unsafe care.

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Nguyen MC, Moffatt-Bruce SD, Strosberg DS, et al. Surgery. 2016;160:858-868.

The AHRQ Patient Safety Indicators (PSIs) rely on hospital administrative data to screen for patient safety problems. This study used independent physician chart review to assess the reliability of PSI 11 (postoperative respiratory failure) in identifying clinically significant patient safety events and found a positive predictive value of 38.3%. The authors argue that PSI 11 should not be used as a measure for hospital performance.

Is there a benefit to multidisciplinary rounds in an open trauma intensive care unit regarding ventilator-associated pneumonia?

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Johnson V, Mangram A, Mitchell C, et al. Am Surg. 2009;75:1171-1174.

This study demonstrated that implementation of multidisciplinary rounds reduced the incidence of ventilator-associated pneumonia in a trauma unit.

Specialty-based, voluntary incident reporting in neonatal intensive care: description of 4846 incident reports.

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Snijders C, van Lingen RA, Klip H, et al. Arch Dis Child Fetal Neonatal Ed. 2009;94:F210-5.

Incident reporting systems are one mechanism for hospitals to both identify and potentially prevent adverse events, although they have frequently failed to meet those expectations. This study describes findings from a voluntary system that produced a significant increase in reported neonatal events, many of which were associated with patient morbidity.

Where's the Feeding Tube?

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WebM&M Case September 1, 2008

A boy was receiving enteral feedings while recovering from a traumatic brain injury. The nasojejunal tube migrated to the gastric area, and the patient developed pneumonia, likely due to aspiration.

How Do Providers Recover From Errors?

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WebM&M Case January 1, 2008

An elderly man with COPD and end-stage congestive heart failure was admitted for increasing shortness of breath, due to a pleural effusion. A resident performed a thoracentesis on the wrong side, and the patient developed a pneumothorax and died. The resident disclosed the error but was devastated.

Accidental iatrogenic pneumothorax in hospitalized patients.

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Zhan C, Smith M, Stryer D. Med Care. 2006;44:182-186.

This Agency for Healthcare Research and Quality (AHRQ)–sponsored study looked at the incidence of accidental iatrogenic pneumothorax (AIP) in patients who underwent certain procedures. They found that AIP occurred most frequently after thoracentesis, but also during other procedures.

Prevention of ventilator-associated pneumonia: an evidence-based systematic review.

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Collard HR, Saint S, Matthay MA. Ann Intern Med. 2003;138:494-501.

Health care–associated infections (HAIs) are a common adverse event in hospitalized patients and an increasing source of study for preventive strategies. Ventilator-associated pneumonia (VAP) is one of the four most common HAIs along with catheter-related bloodstream infection, catheter-associated urinary tract infection, and surgical site infection. This systematic review provides a series of recommendations to reduce the incidence of VAP, including use of semi-recumbent positioning, sucralfate rather than H2-antagonists, and aspiration of subglottic secretions in select patient populations. The authors point out that while many studies highlight the success of preventive strategies, no randomized trial has evaluated the effects of combining the preventive practices as an additive bundle or checklist.

Charcoal Lavage of the Lungs

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WebM&M Case October 1, 2003

Misplacement of an NG tube sends charcoal into the lung; the patient dies of complications.

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