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 166 Results

Access to Clinical Information at the Bedside.

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Farnborough, UK: Healthcare Safety Investigation Branch; February 2023.

Patient misidentification in emergent situations can reduce the appropriateness of care delivery and safety. This report analyzes an incident where the healthcare team misidentified a patient (who had a do-not-resuscitate order) and withheld cardiopulmonary resuscitation (CPR) from the wrong patient. The lack of access to health information technology at the bedside, and reference to the patient’s wristband, were factors contributing to the patient’s death.

Insurance claims for wrong-side, wrong-organ, wrong-procedure, or wrong-person surgical errors: a retrospective study for 10 years.

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Vacheron C-H, Acker A, Autran M, et al. J Patient Saf. 2023;19:e13-e17.

Wrong-site, wrong-procedure, and wrong-patient errors (WSPEs) are serious adverse events. This retrospective analysis of medical liability claims data examined the incidence of WSPEs in France between 2007 and 2017. During this ten-year period, WSPEs accounted for 0.4% of all claims. Procedures on the wrong organ were most common (44%), followed by wrong side (39%), wrong person (13%) and wrong procedure (4%). The researchers found that the average number of WSPEs decreased after implementation of a surgical checklist.

Assessment of the use of patient vital sign data for preventing misidentification and medical errors.

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Maul J, Straub J. Healthcare (Basel). 2022;10:2440.

Patient misidentification can lead to serious medical errors and patient harm. This article provides an overview of how artificial intelligence (AI) frameworks can be combined with patient vital sign data to prevent patient misidentification. The authors suggest that this system could provide alerts indicating possible misidentification or it could be paired with other indicator systems as part of a multi-factor misidentification system.

A longitudinal evaluation of computed tomography radiation incidents within a multisite NHS trust.

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Adamson HK, Foster B, Clarke R, et al. J Patient Saf. 2022;18:e1096-e1101.

Computed tomography (CT) scans are important diagnostic tools but can present serious dangers from overexposure to radiation. Researchers reviewed 133 radiation incidents reported to one NHS trust from 2015-2018. Reported events included radiation incidents, near-miss incidents, and repeat scans. Most events were investigated using a systems approach, and staff were encouraged to report all types of incidents, including near misses, to foster a culture of safety and enable learning.

Serious hazards of transfusion: evaluating the dangers of a wrong patient autologous salvaged blood in cardiac surgery.

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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.

Adding automation and independent dual verification to reduce wrong blood in tube (WBIT) events.

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Passwater M, Huggins YM, Delvo Favre ED, et al. Am J Clin Pathol. 2022;158:212-215.

Wrong blood in tube (WBIT) errors are rare but can lead to complications. One hospital implemented a quality improvement project to reduce WBIT errors with electronic patient identification, manual independent dual verification, and staff education. WBIT errors were significantly reduced and sustained over six years.

Strength of safety measures introduced by medical practices to prevent a recurrence of patient safety incidents: an observational study.

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Müller BS, Lüttel D, Schütze D, et al. J Patient Saf. 2022;18:444-448.

Effective patient safety improvement efforts address safety threats at the individual, interpersonal, and organizational levels. This study characterizes safety measures described in incident reports from German outpatient care settings. Of the 243 preventative measures identified across 160 reports, 83% of preventative measures were classified by the research team as “weak,” meaning that they focus on influencing human behavior rather than on treating underlying problems (e.g., alerts, trainings, double checks).

High-reliability organisation principles implemented in dentistry.

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Minyé HM, Benjamin EM. Br Dent J. 2022;232:879-885.

High reliability organization (HRO) principles used in other high-risk industries (such as aviation) can be applied patient safety. This article provides an overview of how HRO principles (preoccupation with failure, situational awareness, reluctance to simplify, deference to expertise, and commitment to resilience) can be successfully applied in dentistry.

Check Twice, Transport Once

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WebM&M Case May 16, 2022

This WebM&M describes two incidences of the incorrect patient being transported from the Emergency Department (ED) to other parts of the hospital for tests or procedures. In one case, the wrong patient was identified before undergoing an unnecessary procedure; in the second case, the wrong patient received an unnecessary chest x-ray. The commentary highlights the consequences of patient transport errors and strategies to enhance the safety of patient transport and prevent transport-related errors.

Safety in fragile, conflict-affected, and vulnerable settings: An evidence scanning approach for identifying patient safety interventions.

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O’Brien N, Shaw A, Flott K, et al. J Glob Health. 2022;12:04018.

Improving patient safety is a global goal. This literature review explored patient safety interventions focused on people living in fragile, conflict-affected, and vulnerable settings. Studies were generally from lower and lower-middle income countries and focused primarily on strengthening infection prevention and control; however, there is a call for more attention on providing patient safety training to healthcare workers, introducing risk management tools, and reducing preventable harm during care delivery.

Factors associated with wrong blood in tube errors: an international case series - The BEST collaborative study.

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Dunbar NM, Kaufman RM. Transfusion (Paris). 2022;62:44-50.

Wrong blood in tube (WBIT) errors can be classified as intended patient drawn/wrong label applied or wrong patient/intended label applied. In this international study, errors were divided almost evenly between the two types and most were a combination of protocol violations (e.g. technology not used or not used appropriately) and slips/lapses (e.g., registration errors). Additional contributory factors and recommendations for improvement are also discussed.

Descriptive analysis of patient misidentification from incident report system data in a large academic hospital federation.

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Abraham P, Augey L, Duclos A, et al. J Patient Saf. 2021;17:e615-e621.

Patient misidentification errors are common and potentially catastrophic. Patient identification incidents reported in one hospital were examined to identify errors and contributory factors. Of the 293 reported incidents, the most common errors were missing wristbands, wrong charts or notes in files, administrative issues, and wrong labeling. The most frequent contributory factors include absence of patient identity control, patient transfer, and emergency context.

Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions.

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WebM&M Case July 28, 2021

This commentary presents two cases highlighting common medication errors in retail pharmacy settings and discusses the importance of mandatory counseling for new medications, use of standardized error reporting processes, and the role of clinical decision support systems (CDSS) in medical decision-making and ensuring medication safety.

Wrong-patient orders in obstetrics.

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Kern-Goldberger AR, Kneifati-Hayek J, Fernandes Y, et al. Obstet Gynecol. 2021;138:229-235.

Patient misidentification errors can result in serious patient harm. The authors reviewed over 1.3 million electronic orders for inpatients at one New York hospital between 2016 and 2018 and found that wrong-patient order errors occurred more frequently on obstetric units than medical-surgical units. Medication errors were the largest source of order errors and commonly involved antibiotics and opioid and non-opioid analgesics.

Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient Settings.

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Farnborough, UK: Healthcare Safety Investigation Branch; June 3, 2021.

Wrong site/wrong patent surgery is a persistent healthcare never event. This report examines National Health Service (NHS) reporting data to identify how ambulatory patient identification errors contribute to wrong patient care. The authors recommend that the NHS use human factors methods to design control processes to target and manage the risks in the outpatient environment such as lack of technology integration, shared waiting area space, and reliance on verbal communication at clinic.

How can never event data be used to reflect or improve hospital safety performance?

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Olivarius‐McAllister J, Pandit M, Sykes A, et al. Anaesthesia. 2021;76:1616-1624.

UK Regulators measure never events to assess hospital safety culture and dictate reimbursement. The authors suggest that regulators focus on reducing the national never event rate through shared learning and an integrated system-wide approach, rather than concentrating on underperforming, outlier hospitals where factors such as safety culture maybe contributing to increased rates of never events.

Identification of common themes from never events data published by NHS England.

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Omar I, Graham Y, Singhal R, et al. World J Surg. 2021;45:697-704.

Never events can result in serious patient harm and indicate serious underlying organizational safety problems. This study analyzed never events occurring between 2012 and 2020 in the National Health Services and categorized 51 common never events into four categories – wrong site surgery (40% of events); retained foreign objects post-procedure (28%); wrong implant/prosthesis (13%); and non-surgical/infrequent never events (19%). Awareness of these themes may support focused efforts to reduce their incidence and development of specific local safety standards.

Common general surgical never events: analysis of NHS England never event data.

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Omar I, Singhal R, Wilson M, et al. Int J Qual Health Care. 2021;33:mzab045.

Never events, a significant type of adverse event, should never occur in healthcare. This study analyzed 797 surgical never events that occurred from April 2012 to February 2020 in the National Health Service (NHS) England and categorized them into three main categories: wrong-site surgery (53.58%), retained items post-procedure (44.54%), and wrong implant/prosthesis (1.88%). In total 56 common general surgery never events have been found. Being aware of the common themes may help providers to develop more effective strategies to prevent these adverse events.

Health information technology-related wrong-patient errors: context is critical.

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Kim T, Howe J, Franklin E, et al. Patient Safety. 2020;2(4):40–57.

Patient misidentification errors have the potential for serious patient harm. This study analyzed the processes of care involved in 1,189 wrong-patient events. Most errors occurred during ordering/prescribing (42%). One-quarter of all events reached the patient, most commonly involving inappropriate medication administration or receiving the wrong test or procedure. Errors caught before reaching the patient were primarily attributed to information review by nurses, technicians, or other healthcare staff. The authors recommend several strategies for reducing wrong-patient errors.

Registration errors among patients receiving blood transfusions: a national analysis from 2008 to 2017.

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Vijenthira S, Armali C, Downie H, et al. Vox Sang. 2021;116:225-233.

Transfusion errors can have serious consequences. This retrospective analysis used a Canadian national database to characterize patient registration-related errors in the blood transfusion process. Findings indicate that registration errors most commonly occur in outpatient areas and emergency departments and can lead to delays in transfusion.

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