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 490 Results

The Role of Undergraduate Nursing Education in Patient Safety

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Perspective on Safety November 27, 2023

This piece discusses how undergraduate professional nursing education integrates the topic of patient safety into classroom and clinical instruction, and how this affects patient safety as a whole.

In Conversation with Joan Stanley about The Role of Undergraduate Nursing Education in Patient Safety

Joan Stanley is the chief academic officer at the American Association of Colleges of Nursing (AACN). We spoke to her about how undergraduate professional nursing education integrates the topic of patient safety into classroom and clinical instruction, and how this affects patient safety as a whole.

Using in situ simulation to identify latent safety threats in emergency medicine: a systematic review.

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Grace MA, O'Malley R. Simul Healthc. . 2023;Epub Sep 19.

In situ simulation can reveal latent safety threats before they cause harm. This review identified 15 studies of in situ simulations conducted in the emergency department including simulations conducted prior to opening new facilities and to address emerging COVID-19 concerns. The most commonly identified safety threats were related to equipment and team communication.

Medication safety amid technological change: usability evaluation to inform inpatient nurses' electronic health record system transition.

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Reale C, Ariosto DA, Weinger MB, et al. J Gen Intern Med. 2023;38:982-990.

Barcode mediation administration (BCMA) can reduce medication errors, but workarounds can hinder its effectiveness. Using simulations, this study explored potential medication-related errors associated with BCMA during an electronic health record (EHR) transition. The study was able to identify potential problems with both the old and new systems and provide performance data against which to benchmark future system and/or workflow changes.

Observing sources of system resilience using in situ alarm simulations.

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McLoone M, McNamara M, Jennings MA, et al. J Hosp Med. 2023;18:994-998.

Healthcare workers can become desensitized to electronic safety alerts (alert fatigue) which can lead to errors and adverse events. Based on Safety II concepts such as organizational resilience and using in situ simulations of critical hypoxemic-event alarms in pediatric inpatient settings, this study identified four types of system resilience contributing to alarm resilience – secondary notification, team-based care, direct visualization of bedside monitors from outside patient rooms (or a central monitoring station) and presence at the bedside.

Enhancing safety of a system-wide in situ simulation program using no-go considerations.

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Minors AM, Yusaf TC, Bentley SK, et al. Simul Healthc. 2023;18:226-231.

In situ simulations offer unique opportunities to improve teamwork and identify system vulnerabilities. This study examined risks – “no go” considerations - associated with in situ simulations focused on cardiac arrest in pregnancy and identified factors that could lead simulations to be canceled or postponed to ensure patient or staff safety.

Making a move: using simulation to identify latent safety threats before the care of injured patients in a new physical space.

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Kotagal M, Falcone RA, Daugherty M, et al. J Trauma Acute Care Surg. 2023;95:426-431.

Simulation can be used to identify latent safety threats (LSTs) when implementing new workflows or care locations. In this study, simulation scenarios were used to identify LSTs associated with the opening of a new emergency department and critical care area. The 118 identified threats involved equipment, structural or layout issues, resource concerns, and knowledge gaps. Failure mode and effects analysis informed an action plan to mitigate these threats.

Clinical triggers and vital signs influencing crisis acknowledgment and calls for help by anesthesiologists: a simulation-based observational study.

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Matern LH, Gardner R, Rudolph JW, et al. J Clin Anesth. 2023;90:111235.

Effective team communication is essential during crisis management. In this study, 60 anesthesiologists participating in a simulated perioperative anaphylaxis crisis scenario identified common clinical factors prompting crisis acknowledgement.

Improving patients' intensive care admission through multidisciplinary simulation-based crisis resource management: a qualitative study.

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Jensen JF, Ramos J, Ørom M‐L, et al. J Clin Nurs. 2023;32:7530-7542.

Crisis (or crew) resource management (CRM) training focuses on improvement of non-technical skills such as communication, teamwork, and situational awareness. This quality improvement project consisted of simulation-based CRM training in the context of intensive care unit admission. Interviews with participants, conducted three months after the simulation, revealed several themes including reflections on patient safety. Participants described positive changes in workflow, professional standards, and smoother and controlled processes.

Intensive care unit critical incident analysis as an objective tool to select content for a simulation curriculum.

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Yartsev A, Yang F. Simul Healthc. 2023;18:279-282.

Intensive care units (ICUs) are complex care environments at high risk for medical errors. In this retrospective study, researchers identified the occurrence of common ICU scenarios and skills during code blue events and measured trainees’ self-reported confidence in these skills. The analysis found that more than 25% of trainees reported low levels of confidence in three scenarios – familiarity with the advanced life support trolley, electrocardiogram strip interpretation, and operation of an external defibrillator. This process of integrating critical incident data with trainee self-assessment can be generalized to other clinical scenarios to create targeted education and simulation curriculum.

In-situ simulations to detect patient safety threats during in-hospital cardiac arrest.

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Stærk M, Lauridsen KG, Johnsen J, et al. Resusc Plus. 2023;14:100410.

In situ simulation is a valuable tool to identify latent safety threats. In this study, 36 unannounced in situ in-hospital cardiac arrest (IHCA) simulations were conducted across 4 hospitals and identified 30 system errors. Errors were categorized as involving human, organization, hardware, or software errors. These system errors contributed to treatment delays and care omissions.

How does robotic-assisted surgery change OR safety culture?

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AMA J Ethics. 2023;25:E615-E623.

The safety culture of an operating room is known to affect teamwork and patient outcome. This article discusses the unique characteristics of robotic-assisted surgical practice and approaches teams and organizations can take to enhance communication that supports a safe care culture.

Videos of simulated after action reviews: a training resource to support social and inclusive learning from patient safety events.

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McCarthy SE, Hogan C, Jenkins L, et al. BMJ Open Qual. 2023;12:e002270.

Debriefing after significant clinical events helps affected staff develop a shared mental model of what happened, why it happened, and how it can be prevented in the future. This paper describes development of training videos on after action reviews (AAR)s, a type of debriefing. The videos introduce AAR, show a simulated AAR debriefing, offer techniques for handing challenging situations within an AAR, and reflections on the benefits. The videos are available with the online version of the paper.

Video review of simulated pediatric cardiac arrest to identify errors/latent safety threats: a mixed methods study.

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Garcia-Jorda D, Nikitovic D, Gilfoyle E. Simul Healthc. 2023;18:232-239.

Simulation trainings are widely used to identify safety threats and improve processes. By analyzing video recordings of pediatric cardiac arrest simulations, researchers were able to identify 5 main areas of errors: clinical, planning and execution, communication, distraction, and knowledge/training. Investigating the root causes of these errors can result in improved trainings and, thus, improved patient outcomes.

Virtual Nursing: Improving Patient Care and Meeting Workforce Challenges

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Perspective on Safety August 30, 2023

This piece discusses virtual nursing, an approach to care that incorporates an advanced practice nurse into hospital-based patient care through telehealth. Virtual nursing increases patient safety and may enable expert nurses to continue to meet patient needs in future staffing shortages.

In Conversation with Kathleen Sanford and Sue Schuelke about Virtual Nursing

Kathleen Sanford is the chief nursing officer and an executive vice president at CommonSpirit. Sue Schuelke is an assistant professor at the College of Nursing–Lincoln Division, University of Nebraska Medical Center. They have pioneered and tested a new model of nursing care that utilizes technology to add experienced expert nurses to care teams, called Virtual Nursing.

Building Capacity for Patient Safety

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Perspective on Safety July 31, 2023

This piece focuses on the importance of building the capacity of the workforce and organizations for patient safety using patient safety education.

In Conversation with Regina Hoffman about Building Capacity for Patient Safety

Regina Hoffman is the executive director of the Pennsylvania Patient Safety Authority. We spoke to her about her experience in collaborative learning, sharing information across healthcare facilities, and patient safety education.

Patient Safety/Quality Improvement Primer.

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Otolaryngol Head Neck Surg. 2018-2023.

Otolaryngology-head and neck surgery is vulnerable to wrong site errors and other challenges present in surgical care. This series of articles highlights key areas of importance for the specialty as they work to enhance patient safety. The latest 2023 installment covers measurement.

Statewide perinatal quality improvement, teamwork, and communication activities in Oklahoma and Texas.

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Stierman EK, O'Brien BT, Stagg J, et al. Qual Manag Health Care. 2023;32:177-188.

Maternal morbidity and mortality remain a significant problem in U.S. health care. This article describes Texas and Oklahoma’s adoption of a perinatal quality improvement initiative, including the implementation of the Alliance for Innovation of Maternal Health (AIM) patient safety bundles and use of teamwork and communication tools in obstetric units. Findings suggest that adoption of initiative components varies across obstetric units; the majority of units had standardized processes for serious events (obstetric hemorrhage, massive transfusion, severe hypertension) but fewer units offered regular training on effective teamwork and communication for their staff.

Content analysis of nurses' reflections on medication errors in a regional hospital.

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Issacs AN, RAYMOND A, KENT B. Contemp Nurse. 2023;59:202-213.

Despite widespread improvement efforts, medication administration errors (MAE) remain a patient safety problem. In this study, nurses at one Australian hospital provided a reflection as to why they believed an MAE occurred and these reflections were subsequently analyzed using a human factors framework. Individual characteristics, nature of the work, and physical environment factors were identified as contributing to MAE and represent areas for improvement.

In situ simulation as a quality improvement tool to identify and mitigate latent safety threats for emergency department SARS-CoV-2 airway management: a multi-institutional initiative.

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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.

Room of horrors simulation in healthcare education: a systematic review.

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Lee SE, Repsha C, Seo WJ, et al. Nurse Educ Today. 2023;126:105824.

“Horror room” simulations are used to help train medical students to identify patient safety hazards. This systematic review of 16 studies found that “horror room” simulations are more common in Western countries and focus on medication-related or procedure-related incidents. The authors highlight the need for research establishing parameters regarding the ideal size and composition of the team to yield the highest impact on learners.

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