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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 459 Results
Wallin A, Ringdal M, Ahlberg K, et al. Scand J Caring Sci. 2023;37:414-423.
Numerous factors can hinder safe radiology practices, such as communication failures and image interpretation errors. Based on semi-structured interviews with 17 radiologists in Sweden, this study identified 20 themes at the individual-, organization-, technology-, task-and environment-levels describing factors supporting patient safety in radiology. Factors described by participants included the use of standardized tools and work routines (e.g., checklists), handoffs, and incident reporting systems.
Hose B-Z, Carayon P, Hoonakker PLT, et al. Appl Ergon. 2023;113:104105.
Health information technology (IT) usability continues to be a source of patient harm. This study describes the perspectives of a variety of pediatric trauma team members (e.g., pediatric emergency medicine attending, surgical technician, pediatric intensive care unit attending) on the usability of a potential team health IT care transition tool. Numerous barriers and facilitators were identified and varied across department and role.
Ryan SL, Logan M, Liu X, et al. Jt Comm J Qual Patient Saf. 2023;Epub Jul 31.
I-PASS is a structured tool to improve handoffs and communication between clinicians and promote patient safety. This study examined I-PASS implementation practices over a six-year period in 10 departments at one large academic medical center. Researchers found that most clinical services successfully implemented I-PASS and those using I-PASS conducted the most efficient handovers.
Prior A, Vestergaard CH, Vedsted P, et al. BMC Med. 2023;21:305.
System weaknesses (e.g., resource availability, deficiencies in care coordination) threaten patient safety. This population-based cohort study including 4.7 million Danish adults who interacted with primary or hospital care in 2018, found that indicators of care fragmentation (e.g., higher numbers of involved clinicians, more transitions between providers) increased with patient morbidity level. The researchers found that higher levels of care fragmentation were associated with adverse outcomes, including potentially inappropriate prescribing and mortality.
Loke DE, Green KA, Wessling EG, et al. Jt Comm J Qual Patient Saf. 2023;Epub Jul 2.
Quantitative studies have demonstrated that emergency department (ED) overcrowding and patient boarding contribute to adverse events. This study includes both qualitative and quantitative methods to understand how ED clinicians view the impact of boarding on their own well-being as well as patient safety. Key themes include clinician dissatisfaction and burnout, and high rates of verbal and physical abuse from boarding patients. Possible solutions included improved standardization of care, proactive planning, and culture change hospital-wide.
Williams SR, Sebok-Syer SS, Caretta-Weyer H, et al. BMC Med Educ. 2023;23:434.
Standardizing handoff training in residency programs can lead to safer, more effective handoffs. Researchers surveyed a sample of 687 residents and fellows from over 30 specialties about handoff training perspectives. Participants reported wide variability in handoff content and identified important aspects of handoff training (critical handoff elements, the impact of systems-level factors, impact of the handoff on providers and patients, professional duty, and addressing blame or guilt related to poor handoff experiences).
Kamta J, Fregoso B, Lee A, et al. Prehosp Emerg Care. 2023;Epub Jul 28.
Handoffs from emergency medical services (EMS) to the emergency department (ED) are vulnerable to communication errors due to the time-pressured environment. This study reports on the implementation of an electronic health record (EHR) tool that added pre-hospital medication administration to the ED triage note to reduce medication administration errors (MAE). Although most ED providers reported they "always" review the triage note, MAE rates did not improve following implementation.

Abraham J, Rosen M, Greilich PE eds. Jt Comm J Qual Patient Saf. 2023;49(8):341-434.

Handoffs occur several times during a surgical procedure, increasing the risk of communication mistakes and misunderstandings. This special issue explores perioperative handoffs and strategies to improve them. Topics covered include information accuracy, teamwork science, and artificial intelligence.
Patient Safety Innovation July 31, 2023

Concern over patient safety issues associated with inadequate tracking of test results has grown over the last decade, as it can lead to delays in the recognition of abnormal test results and the absence of a tracking system to ensure short-term patient follow-up.1,2 Missed abnormal tests and the lack of necessary clinical follow-up can lead to a late diagnosis.

Manchester, UK: Parliamentary and Health Service Ombudsman; June 2023. ISBN: 9781528642446.

Lack of accountability for systemic contributions to failure degrades efforts to generate improvement. This report discusses gaps in the British National Health Service patient safety culture. It calls for governmental oversight and commitment as the central activation lever necessary to achieve collective, coordinated effort and motivate large-scale action to support lasting change.
Starmer AJ, Michael MM, Spector ND, et al. Jt Comm J Qual Patient Saf. 2023;49:384-393.
Multiple handoffs during perioperative care present opportunities for error. This article outlines a conceptual framework to support the development, implementation, and evaluation of patient-centered handoffs during perioperative care. The authors describe a multi-component handoff improvement bundle including mnemonics and checklists (such as I-PASS), technology solutions to reinforce verbal handoffs, interprofessional handoff training and assessment, and leadership support to promote safety culture.
Keebler JR, Lynch I, Ngo F, et al. Jt Comm J Qual Patient Saf. 2023;49:373-383.
Handoffs are an inevitable part of hospital care; clear communication between providers is required to ensure safe care. This quality improvement project aimed to improve handoffs between the cardiovascular (CV) operating room and CV intensive care unit by developing, implementing, and sustaining a structured handoff bundle. A participatory design was used to ensure that the tool contained only the key elements to support implementation without overburdening users.
Conn Busch J, Wu J, Anglade E, et al. Jt Comm J Qual Patient Saf. 2023;49:365-372.
Structured handoffs are recognized as a method to ensure that complete, accurate information is shared between teams. This article describes the impact of the Handoffs and Transitions in Critical Care (HATRICC) study on accuracy and completeness of handoff before and after implementation of a structured handoff tool. Post-intervention, the accuracy and completeness of handoffs improved. Omissions, mortality, and length of intensive care unit (ICU) stay were reported in a 2019 study.

Santhosh L, Cornell E, Rojas JC, et al. Rockville, MD: Agency for Healthcare Research and Quality; June 2023. AHRQ Publication No. 23-0040-1-EF.

Care transitions present opportunities for errors. This issue brief highlights the risk of diagnostic errors during transitions in care, such as from the emergency department to the inpatient floor or from inpatient to outpatient care. The brief describes strategies to prevent and reduce these errors, such as diagnostic feedback or structured handoff tools.
Ming Y, Meehan R. J Patient Saf. 2023;19:369-374.
Health care workers’ perception of safety is an important indicator of safety culture. Using data from the 2021 AHRQ Hospital Survey on Patient Safety Culture™ (SOPS®), these researchers examined individual and organizational factors influencing perceived patient safety ratings. Findings indicate that nurses have lower patient safety perceptions compared to other job types and that organizational factors such as organizational learning, leadership support, and ease of handoffs and information exchange, were all associated with higher perceived patient safety. 
WebM&M Case June 14, 2023

A 63-year-old man presented from a skilled nursing facility (SNF) with shortness of breath and was treated for mild heart failure exacerbation. An echocardiogram was performed but results were pending on discharge, with anticipation that the patient’s primary care provider would follow up the results. Two weeks later, the patient was readmitted from the SNF and was found to have endocarditis and infected pacemaker wires.

Tataei A, Rahimi B, Afshar HL, et al. BMC Health Serv Res. 2023;23:527.
Patient handoffs present opportunities for miscommunication and errors. This quasi-experimental study examined the impact of an electronic nursing handover system (ENHS) on patient safety and handover quality among patients both with and without COVID-19 in the intensive care unit (ICU). Findings indicate that the ENHS improved the quality of the handover, reduced handover time, and increased patient safety.
Sparling J, Hong Mershon B, Abraham J. Jt Comm J Qual Patient Saf. 2023;49:410-421.
Multiple handoffs can occur during perioperative care, which can increase the risk for errors and patient harm. This narrative review summarizes research on the benefits, limitations, and implementation challenges of electronic tools for perioperative handoffs and the role of artificial intelligence (AI) and machine learning (ML) in perioperative care.
Patient Safety Innovation May 31, 2023

Seeking a sustainable process to enhance their hospitals’ response to sepsis, a multidisciplinary team at WellSpan Health oversaw the development and implementation of a system that uses customized electronic health record (EHR) alert settings and a team of remote nurses to help frontline staff identify and respond to patients showing signs of sepsis. When the remote nurses, or Central Alerts Team (CAT), receive an alert, they assess the patient’s information and collaborate with the clinical care team to recommend a response.

Patient Safety Innovation May 31, 2023

Patient falls in hospitals are common and debilitating adverse events that persist despite decades of effort to minimize them. Improving communication across the assessing nurse, care team, patient, and patient’s most involved friends and family may strengthen fall prevention efforts. A team at Brigham and Women’s Hospital in Boston, Massachusetts, sought to develop a standardized fall prevention program that centered around improved communication and patient and family engagement.