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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 315 Results

Institute for Healthcare Improvement. Mar 14 - May 16, 2023.

Root cause analysis (RCA) is a widely recognized retrospective strategy for learning from failure that is challenging to implement. This series of webinars will feature an innovative approach to RCA that expands on the concept to facilitate its use in incident investigations. Instructors for the series will include Dr. Terry Fairbanks and Dr. Tejal K. Gandhi.

Collaborative for Accountability and Improvement.  January 26, 2023, 2:00-3:00 PM (eastern).

Root cause analysis (RCA) is a recognized approach to examining failures by identifying causal factors to define improvement effort. This session will discuss challenges to the effective use of RCA results and examine an approach to present them that supports effective improvement action.
Uramatsu M, Maeda H, Mishima S, et al. J Cardiothorac Surg. 2022;17:182.
Wrong-patient transfusion errors can lead to serious patient harm. This case report describes a blood transfusion error and summarizes the systems issues that emerged during the root case analysis, as well as the corrective steps implemented by the hospital to prevent future transfusion errors. A previous Spotlight Case featured a near-miss transfusion error and strategies for ensuring safe transfusion practices.
St Paul, MN: Minnesota Department of Health.
The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2021 report summarizes information about 508 adverse events that were reported, representing a significant increase in the year covered. Earlier reports document a fairly consistent count of adverse events. The rise reflected here is likely due to demands on staffing and care processes associated with COVID-19. Pressure ulcers and fall-related injuries were the most common incidents documented. Reports from previous years are available.
Wolf L, Gorman K, Clark J, et al. J Patient Saf. 2022;18:e1160-e1166.
Human factors play an important role in contributing to and preventing adverse events. This study found that integrating human factors into a new root cause analysis process led to an increase in the number of strong interventions implemented after adverse events.
Driesen BEJM, Baartmans M, Merten H, et al. J Patient Saf. 2022;18:342-350.
Root cause analysis (RCA) is widely used to investigate, monitor, and learn from unintended events (UE). One method of RCA is the Prevention and Recovery Information System for Monitoring and Analysis (PRISMA)-method. This review identified 25 studies that used the PRISMA method to analyze UEs. Combining record reviews with provider interviews and using multiple PRISMA-trained researchers may increase the number of causes identified.
Politi RE, Mills PD, Zubkoff L, et al. J Patient Saf. 2022;18:e1061-e1066.
Delays in diagnosis and treatment can lead to poor outcomes for patients. Researchers reviewed root cause analysis (RCA) reports to identify factors contributing to delays in diagnosis and treatment among surgical patients at the Veterans Health Administration. Of the 163 RCAs identified, 73% reflected delays in treatment, 15% reflected delays in diagnosis, and 12% reflected delays in surgery. Policies and processes (e.g., lack of standardized processes, procedures not followed correctly) was the largest contributing factor, followed by communication challenges, and equipment or supply issues.
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.
Rhodus EK, Lancaster EA, Hunter EG, et al. J Patient Saf. 2022;18:e503-e507.
Patient falls represent a significant cause of patient harm. This study explored the causes of falls resulting in harm among patients with dementia receiving or referred to occupational therapy (OT). Eighty root cause analyses (RCAs) were included in the analysis. Of these events, three-quarters resulted in hip fracture and 20% led to death. The authors conclude that earlier OT evaluation may decrease the frequency of falls among older adults with dementia.
Patient Safety Primer March 30, 2022

This primer provides a broad overview of three widely used tools for investigating and responding to patient safety events and near misses. Tools covered in this primer are incident reporting systems, Root Cause Analysis (RCA), and Failure Modes and Effects Analysis (FMEA). These tools have been used in high-risk industries and occupations such as aviation, manufacturing, nuclear power, and the military and have been adapted for use in enhancing patient safety in healthcare settings over the past two decades.

Shah F, Falconer EA, Cimiotti JP. Qual Manag Health Care. 2022;31:231-241.
Root cause analysis (RCA) is a tool commonly used by organizations to analyze safety errors. This systematic review explored whether interventions implemented based on RCA recommendations were effective at preventing similar adverse events in Veterans Health Affairs (VA) settings. Of the ten retrospective studies included in the review, all reported improvements following RCA-recommended interventions implementation, but the studies used different methodologies to assess effectiveness. The authors suggest that future research emphasize quantitative patient-related outcome measures to demonstrate the impact and value of RCAs.
Siewert B, Swedeen S, Brook OR, et al. Radiology. 2022;302:613-619.
Adverse events can contribute to physical, financial, or emotional harm. Based on radiology-related events identified in a hospital incident reporting system, the authors identified the types of incidents contributing to emotional harm in patients – failure to be patient-centered, disrespectful communication, privacy violations, minimization of patient concerns, and loss of property. The authors also proposed several improvement strategies, including communication training and improvement of communication processes, individual feedback, and improvements to existing processes and systems.
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.

Washington, DC: Veterans Affairs Office of Inspector General; August 26, 2021. Report No. 21-01502-240.

Organizational assessments often provide insights that address overarching quality and safety challenges. This extensive inspection report shares findings from inspections of 36 Veterans Health Administration care facilities. Recommendations drawn from the analysis call for improvements in suicide death review, root cause analysis result application, and safety committee action item implementation.
Mills PD, Watts BV, Hemphill RR. J Patient Saf. 2021;17:e423-e428.
Researchers reviewed 15 years of root cause analysis reports of all instances of suicide and suicide attempts on Veterans Health Administration (VHA) grounds. Forty-seven suicides or suicide attempts were identified, and primary root causes included communication breakdown and a need for improved suicide interventions. The paper includes recommended actions to address the root causes of attempted and completed patient suicides.
Ziemba JB, Berns JS, Huzinec JG, et al. Acad Med. 2021;96:997-1001.
Root cause analysis (RCA) is a common method to investigate adverse events and identify contributing factors. To expand resident understanding of and participation in RCA, the authors developed simulated RCAs that were applicable to a broad set of specialties and included other healthcare professionals whose disciplines were involved in the event (e.g., nurses, pharmacists). After participating in the simulated RCAs, there was an increase in trainees understanding of RCA and intent to report adverse events.
Abela G. J Tissue Viability. 2021;30:339-345.
Hospital-acquired pressure injuries (HAPI) can lead to increase costs and length of stay. Through root cause analysis, this geriatric rehabilitation hospital identified factors that contributed to the development of HAPI in its facility. Recommendations for improvement targeted both system- and human-level factors.
Norris B, Soncrant C, Mills PD, et al. Jt Comm J Qual Patient Saf. 2021;47:489-495.
Opioid misuse and overdose continues to be a patient safety concern. This study conducted root cause analyses of 82 adverse event reports involving opioid use at the Veterans Health Administration. The most frequent event type was medication administration error and the most frequent root cause was staff not following hospital policies or hospitals not having opioid-related policies. 
Smits M, Langelaan M, de Groot J, et al. J Patient Saf. 2021;17:282-289.
This study used trained reviewers to examine root causes of adverse events in 571 deceased hospital patients in the Netherlands. Preventable adverse events were commonly caused by technical, organizational, and human causes; technical causes also commonly contributed to preventable deaths from adverse events. The authors discuss strategies to reduce adverse events, including improving communication and information structures, evaluating safety behaviors, and continuous monitoring of patient safety and quality data.