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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 37 Results

Sentinel Event Alert. June 22, 2022;(65):1-7.

A clinician's knowledge of an existing condition can implicitly affect treatment recommendations and decisions. This alert highlights the presence of diagnostic overshadowing as a type of bias that is prone to affect disadvantaged or stigmatized patient populations. Listening training programs, improved use of patient data review, and assessment techniques are recommended to trigger diagnostic curiosity to encourage complete decision-making methods when serving patients.

Sentinel Event Alert. Nov 10 2021;(64):1-7.

Health care disparities are emerging as a core patient safety issue. This alert introduces strategies to align organizational and patient safety strategic goals, such as collection and analysis of community-level performance data, adoption of diversity and inclusion as a precursor to improvement, and development of business cases to support inequity reduction initiatives.
Sentinel Event Alert. 2018;59:1-9 (revised June 18, 2021).
The Joint Commission issues sentinel event alerts to raise awareness regarding risks in the health care setting. This alert highlights physical and verbal violence as a major problem in the workplace, particularly in areas such as the emergency department and inpatient psychiatric units. Other factors associated with violence in health care settings include stressful conditions, understaffing, and lack of organizational policies for recognizing and deescalating hostile behaviors. The alert suggests numerous strategies health care organizations can take to mitigate workplace violence, such as establishing systems across the organization that enable reporting of workplace violence and developing quality improvement initiatives to reduce such incidents. A past PSNet perspective explored how a team at Beth Israel Deaconess Medical Center developed a process to improve workplace safety.
Sentinel Event Alert. 2010:1-3.
Revised June 2021. The Joint Commission issues sentinel event alerts to highlight areas of high risk and to promote rapid adoption of risk reduction strategies. This newly released alert focuses on violence in the health care setting, noting increasing rates of violent crimes such as assault, rape, and homicide, which are consistently among the top 10 types of sentinel events reported. Controlling access is viewed as a key protection strategy, and the alert also outlines techniques for identifying violent individuals and for training staff in violence management. The alert summarizes a series of suggested actions that will allow organizations to safeguard against these events. Adherence to sentinel event alert recommendations is assessed as part of Joint Commission accreditation surveys.
Jt Comm J Qual Patient Saf. 2021;47:394-397.
Smart infusions pumps with built-in dose error reduction software (DERS) are designed to protect against dosing errors that result in patient harm. This alert summarizes recommendations to enhance the effective implementation and use of smart infusion pumps such as drug library maintenance and pump error report monitoring.

Sentinel Event Alert. Feb 2, 2021;(62):1-7. 

Safe patient care is reliant on a healthy healthcare workforce. This alert emphasizes organizational conditions and supporting the wellbeing of clinicians under the stress of providing care during the COVID-19 pandemic. 

Sentinel Event Alert. July 30, 2019;(61):1-5.

Anticoagulant medications are known to be high-risk for adverse drug events. Although direct oral anticoagulants (DOACs) require less monitoring than warfarin, they are still associated with an increased risk of patient harm if not prescribed and administered correctly. The Joint Commission has issued a new sentinel event alert to raise awareness of the risks related to DOACs, and in particular, the challenges associated with stopping bleeding in patients on these medications. The alert suggests that health care organizations develop patient education materials, policies, and evidence-based guidelines to ensure that DOACs and reversal agents are used appropriately. A past WebM&M commentary discussed common errors related to the use of DOACs.
Sentinel event alert. 2018:1-8.
Although adverse events and near misses are common in health care, they are almost ubiquitously underreported. Barriers to reporting include health care provider fear of repercussions, insufficient integration of reporting systems into the electronic health record, and cultural factors. This new sentinel event alert explores how organizations can change their culture to promote reporting. It highlights bright spots: organizations that use a just culture approach to investigating errors, celebrate employees who report safety hazards, and whose leaders prioritize reporting. The Joint Commission proposes actions for all organizations to take, including developing incident reporting systems, promoting leadership buy-in, engaging in systemwide communication, and implementing transparent accountability structures. An Annual Perspective reviewed the context of the no-blame movement and the recent shift toward a framework of a just culture.
Sentinel event alert. 2017;58:1-6.
The Joint Commission publishes sentinel event alerts to draw attention to pressing or emerging safety issues and provide guidelines for organizations on how to address them. This alert highlights potential safety hazards at the time of handoffs, defined as "a transfer and acceptance of patient care responsibility achieved through effective communication." Handoffs can occur within or across settings of care (e.g., between two clinicians in the same hospital or between a hospital and a long-term care facility). To ensure high-quality handoffs, the alert recommends that health care organizations take several actions, including providing handoff training to clinicians, engaging leadership in prioritizing handoffs as an essential part of a culture of safety, and using continuous improvement methodology to monitor and enhance handoffs. High-quality research has defined effective communication techniques for preventing handoff errors (such as the I-PASS mnemonic), and the alert specifically recommends use of these tools. A past WebM&M commentary discussed a handoff error that nearly resulted in serious patient harm.
Sentinel Event Alert. 2017;57:1-8.
The Joint Commission issues sentinel event alerts to highlight commonly reported, novel, or previously unrecognized safety concerns and make recommendations for how to address these critical safety issues. This newly released alert emphasizes the link between leadership and a positive safety culture. Leaders can model a nonpunitive approach to error reporting and investigation, and they should ensure that unprofessional or intimidating behavior is not tolerated. The alert recommends periodic measurement of safety culture using a validated tool such as the AHRQ Hospital Survey on Patient Safety Culture or the Safety Attitudes Questionnaire. Safety assessments should then be used to inform team training and quality improvement efforts. A past PSNet perspective discussed the role of leadership in patient safety.
Sentinel event alert. 2016:1-7.
The Joint Commission publishes sentinel event alerts to emphasize pressing safety issues, determine root causes, and provide guidelines for organizations on how to address them. In light of receiving 1089 reports of suicide between 2010 and 2014, this new alert focuses on preventing suicide in health care settings. Many of the suicide cases investigated across health care settings had involved inadequate assessments or lack of identification of suicidal ideation. The alert suggests that all health care providers should screen for suicidal ideation and review patients for suicide risk factors. A previous WebM&M commentary discusses a suicide attempt on an inpatient medical unit. Note: This alert has been retired effective February 2019. Please refer to the information link below for further details.

Sentinel Event Alert. September 28, 2015;(55):1-5.

Falls in the hospital are common, particularly among elderly patients, and falls resulting in serious injury or death are considered never events. This sentinel event alert identified 465 such cases reported to The Joint Commission since 2009 and acknowledges that preventing falls is difficult and complex. The Joint Commission recommends several strategies for preventing falls, including identifying patients at risk for falls, establishing a multidisciplinary fall prevention team, using patient-specific approaches to minimize fall risk, and conducting a post-fall multidisciplinary huddle to detect system flaws. These strategies have been successfully applied and shown to reduce falls in high-quality studies. The role of the physical environment as a risk for falls and the use of post-fall huddles are discussed in a recent AHRQ WebM&M commentary.

Sentinel Event Alert. March 31, 2015;(54):1-6.

The introduction of information technology (IT) has transformed health care, but it is clear that the rapid uptake of IT has profoundly changed clinician workflow, resulting in unintended consequences that in some cases have harmed rather than helped patients. These unintended consequences include new types of errors resulting from computerized provider order entry, alarm fatigue arising from the proliferation of well-intended safety alerts, and problems with poor interoperability of different electronic medical record systems. The Joint Commission issues sentinel event alerts periodically to highlight emergent safety issues, and this alert describes some of the 120 sentinel events reported to The Joint Commission since 2003 that were determined to be related to IT. Several recommendations to prevent IT–related safety threats are discussed, including improving safety culture by creating a shared sense of responsibility between users and developers, paying careful attention to safe IT implementation, and engaging leadership to provide oversight in health IT planning, implementation, and evaluation. The hazards and benefits of health IT are the subject of a recent book by a prominent patient safety expert.

Sentinel Event Alert. August 20, 2014;(53):1-6.

The Joint Commission issues sentinel event alerts in response to significant emerging safety risks for events which carry high risk and require immediate action. This alert reports on new standards for tubing connectors to prevent injury from incorrect administration of therapeutic agents. New ISO (International Organization for Standardization) standards prevent one type of tubing (such as intravenous) to be incorrectly attached to a different delivery system (such as a feeding tube.) The Joint Commission recommends multidisciplinary review of existing tubing connectors, maintaining awareness of the possibility for incorrect connections, and preparing and adopting safety connectors as soon as they are available in late 2014. A past AHRQ WebM&M commentary describes an administration error due to incorrect tubing connection.
Sentinel Event Alert. 2014;June 16:1-6.
The Joint Commission has issued a sentinel event alert regarding infections caused by the misuse of vials, prompted by at least 49 outbreaks related to this problem since 2001. The reuse of single-dose vials has resulted in documented transmission of bacteria and hepatitis B and C viruses. Most outbreaks occurred in hospitals, but a large number of cases also came from outpatient pain management and cancer clinics. More than 150,000 patients required notification and further testing due to concern of potential exposure to unsafe injections. This alert outlines recommendations and potential strategies for improvement, including resources related to the Centers for Disease Control and Prevention's (CDC) One & Only Campaign, which promotes using "one needle, one syringe, only one time." The report also emphasizes teaching safe practices and establishing safety culture. CDC has previously issued guidelines on appropriate use of single-dose vials.
Commission J. Sentinel event alert. 2013:1-5.
Sentinel event alerts are issued periodically by The Joint Commission to identify common or emerging patient safety problems and provide organizations with approaches for addressing these issues. A retained foreign object (RFO)—surgical materials or equipment unintentionally left in a patient's body after completing the operation—is a never event that can have serious clinical consequences. Despite being long recognized as a critical—and preventable—error, RFOs continue to occur, with nearly 800 cases being reported to The Joint Commission between 2005 and 2012. This alert makes several recommendations to help prevent RFOs, including focusing on enhancing the reliability of the traditional manual count of instruments and materials used during a procedure, improving safety culture in the operating room through interventions (e.g., teamwork training), and investigating technological approaches (e.g., bar coding of surgical sponges) to ease identification of potentially missing objects before patients are harmed.
Commission J. Sentinel event alert. 2013:1-3.
The cacophony of alarms in hospitals has led many health care providers to become desensitized to them, a condition known as alarm fatigue. This sentinel event alert describes how ignoring alarms can have fatal outcomes and recounts an intensive care unit death due to providers' lack of response to alarms signaling a patient's clinical decline. The sentinel event database includes 98 alarm-related events (80 of which resulted in death) between 2009 and June 2012. Because the database relies on voluntary reporting, this number likely represents a small proportion of actual events. The report outlines recommendations and potential strategies for improvement, including guideline development, training and education, and establishment of a cross-disciplinary team of clinicians, clinical engineers, information technologists, and risk managers focused on alarm safety. The Joint Commission is also considering developing a related National Patient Safety Goal to address this issue.
Sentinel Event Alert. 2012;49:1-5.
Opioid pain medications are considered high-risk medications due to the potential for respiratory depression and other adverse effects. Because these medications are frequently used to treat acute pain in the hospital, opioids account for a disproportionate share of preventable adverse drug events. This sentinel event alert, issued by The Joint Commission to highlight particularly important safety issues, calls for hospitals to implement standardized methods to assess and monitor acute pain, ensure education for clinicians on appropriate opioid usage, and use information technology to support safe opioid prescribing. A serious case of opioid overdose is discussed in this AHRQ WebM&M commentary.  Note: This alert has been retired effective February 2019. Please refer to the information link below for further details.

Sentinel Event Alert. August 24, 2011;47:1-4. (revised February 2019).

The Joint Commission issues Sentinel Event Alerts periodically to highlight emerging patient safety issues and stimulate innovative approaches to addressing these threats. The overuse of diagnostic imaging, particularly computed tomographic (CT) scans, poses patient safety risks due to excess radiation exposure. More than 70 million CT scans are performed in the United States every year, and the radiation exposure from these scans may lead to thousands of cancer-related deaths. This alert reviews specific strategies organizations should take to minimize radiation risks, including educating physicians on appropriate test utilization, standardizing equipment and radiation dosage, and promoting a culture of safety. An AHRQ WebM&M commentary discusses factors that may contribute to overutilization of diagnostic imaging, with consequent short- and long-term risks to patients.