Skip to main content

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.

Search All Content

Search Tips
Selection
Format
Download
Filter By Author(s)
Advanced Filtering Mode
Date Ranges
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Additional Filters
Approach to Improving Safety
Clinical Area
Safety Target
Selection
Format
Download
Displaying 1 - 20 of 150 Results
WebM&M Case November 30, 2023

A 38-year-old woman with class 3 obesity required removed of a gastric balloon under general anesthesia. She required a relatively large dose of rocuronium for endotracheal intubation, and she was given intravenous sugammadex (200 mg) at the end of the procedure to reverse the neuromuscular block. A quantitative neuromuscular block monitor was not used, but reliance was placed on clinical signs. Shortly after arrival in the post-anesthesia care unit, she couldn’t move or open her eyes and became jittery with low oxygen saturation.

Ravindran S, Matharoo M, Rutter MD, et al. Endoscopy. 2023;Epub Sept 18.
Understanding the influence of human factors on team and system performance can help safety professionals identify opportunities for improvement. In this study, researchers used a large, centralized incident reporting database in the United Kingdom to examine the human factors contributing to non-procedural endoscopy-related patient safety incidents. Based on Human Factors Analysis and Classification System coding, decision-based errors were the most common factor contributing to incidents, but other contributing factors were also identified, including lack of resources and ineffective team communication.

National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2023. ISBN: 9780309711937.

Maternal health care is rapidly emerging as a high-risk service that is vulnerable to communication, equity, and diagnostic challenges. This report examines the role of disparities in care across the maternal care continuum and strategies to drive diagnostic improvement such as care bundles, midwives, and health information technology. This publication is from a series of programs and resultant publications on improving diagnostic excellence.
Bauer ME, Albright C, Prabhu M, et al. Obstet Gynecol. 2023;142:481-492.
Reducing maternal morbidity and mortality is a critical patient safety priority. Developed by the Alliance for Innovation on Maternal Health (AIM), this patient safety bundle provides guidance for healthcare teams to improve the prevention, recognition, and treatment of infections and sepsis among pregnant and postpartum patients.
Liberati EG, Martin GP, Lamé G, et al. BMJ Qual Saf. 2023;Epub Sep 21.
“Safety cases” are used in healthcare and other industries to communicate the safety of a product, system, or service. In this study, researchers use the “safety case” approach to evaluate the safety of the Safer Clinical Systems program, which is designed to improve the safety and reliability of clinical pathways.  
WebM&M Case September 27, 2023

This case describes an older adult patient with generalized abdominal pain who was eventually diagnosed with inoperable bowel necrosis. Although she appeared well and had stable vital signs, triage was delayed due to emergency department (ED) crowding, which is usually a result of hospital crowding. She was under-triaged and waited three hours before any diagnostic studies or interventions commenced. Once she was placed on a hallway gurney laboratory and imaging studies proceeded hastily.

Ojeda IM, Sánchez-Cuervo M, Candela-Toha Á, et al. Crit Care Nurs. 2023;43:30-38.
High-alert medications can cause serious patient harm if administered incorrectly. This article describes a quality improvement project to reduce medication errors involving high-alert sedative and analgesic medications in the intensive care unit (ICU) through use of protocolized and centralized smart intravenous infusion pump technology. Use of the protocolized software led to the interception of nearly 400 infusion-related programming errors.
Grubenhoff JA, Bakel LA, Dominguez F, et al. Jt Comm J Qual Patient Saf. 2023;49:547-557.
Clinical care pathways (CP) standardize care to ensure evidence-based practices are consistently followed. This study analyzed missed diagnostic opportunities (MDO) of pediatric musculoskeletal infections that could have been mitigated had the CP recommendations been adhered to. Misinterpretation of laboratory results was a critical contributor to MDO by both pediatric emergency providers and orthopedic consultants.
Pisani AR, Boudreaux ED. Focus (Am Psychiatr Publ). 2023;21:152-159.
Identifying patients with suicidal ideation can be a challenging clinical problem in the emergency department. These authors use a systems-based approach to identify missed opportunities to prevent suicide and present a systems approach to suicide prevention including three core domains – a culture of safety and prevention, applying best practices and policies for prevention in systems, and workforce education and development.

Institute for Safe Medication Practices. May 2023.

The integration of best practices into daily work is an indication of their usefulness and sustainability. This survey seeks to understand the broad use of 2022-2023 Targeted Medication Safety Best Practices for Hospitals throughout health care to determine implementation successes and barriers. Data submission closes June 30, 2023.
Saint S, Greene MT, Krein SL, et al. Infect Control Hosp Epidemiol. 2023;Epub Jun 1.
The COVID-19 pandemic challenged infection prevention and control practices. Findings from this survey of infection prevention professionals from acute care hospitals in the United States found that while CLABSI and VAE preventive practices either increased or remained consistent, use of CAUTI preventive practices decreased during the pandemic.
Jones BE, Sarvet AL, Ying J, et al. JAMA Netw Open. 2023;6:e2314185.
Pneumonia is one of the most common healthcare-acquired infections and can result in significantly longer lengths of stay and increased costs. In this retrospective study of more than six million hospitalized Veterans Health Administration patients, approximately 1 in 200 patients developed non-ventilator-associated hospital-acquired pneumonia (NV-HAP). Length of stay and mortality were significantly higher for patients with NV-HAP.
WebM&M Case March 29, 2023

A 48-year-old obese man with a history of obstructive sleep apnea was placed under general anesthesia for corneal surgery. On completion of the operation, the patient was transferred to a motorized gurney to extubate him in a sitting position because the operating room (OR) table was too narrow. However, while the team was moving him from the OR table to the gurney, a nurse inadvertently pulled on the anesthetic machine hoses. The endotracheal tube became dislodged and the patient could not be ventilated.

Morgan DJ, Malani PN, Diekema DJ. JAMA. 2023;329:1255-1256.
The effective use of resources through stewardship initiatives can support error reduction through focusing actions of care. This commentary discusses how diagnostic stewardship can enhance diagnostic testing behaviors across the diagnostic process.
Liberman AL, Holl JL, Romo E, et al. Acad Emerg Med. 2022;30:187-195.
A missed or delayed diagnosis of stroke places patients at risk of permanent disability or death. This article describes how interdisciplinary teams used a failure modes, effects, and criticality analysis (FMECA) to create an acute stroke diagnostic process map, identify failures, and highlight existing safeguards. The FMECA process identified several steps in the diagnostic process as the most critical failures to address, including failure to screen patients for stroke soon after presentation to the Emergency Department (ED), failure to obtain an accurate history, and failure to consider a stroke diagnosis during triage.
Tawfik DS, Adair KC, Palassof S, et al. Jt Comm J Qual Patient Saf. 2023;49:156-165.
Leadership across all levels of a health system plays an important role in patient safety. In this study, researchers administered the Safety, Communication, Operational, Reliability, and Engagement (SCORE) survey to 31 Midwestern hospitals to evaluate how leadership behaviors influenced burnout, safety culture, and engagement. Findings indicate that local leadership behaviors are strongly associated with healthcare worker burnout, safety climate, teamwork climate, workload, and intentions to leave the job.
WebM&M Case February 1, 2023

A 27-year-old pregnant woman was diagnosed with severe pulmonary arterial hypertension at 29 weeks estimated gestational age (EGA) and admitted for elective cesarean delivery with lumbar epidural anesthesia at 36 weeks EGA. After epidural catheter placement, she suddenly became bradycardic and hypotensive, and within 3 minutes, developed pulseless electrical activity and cardiopulmonary resuscitation (CPR) began immediately. An emergent cesarean delivery was performed.

Curated Libraries
January 19, 2023
The Primary-Care Research in Diagnosis Errors (PRIDE) Learning Network was a Boston-based national effort to improve diagnostic safety. Hosted by the State of Massachusetts’ Betsy Lehman Center, it was led by the Harvard Brigham and Women’s Center for Patient Safety Research and Practice with funding from the Gordon and Betty Moore Foundation. ...
Carlile N, Fuller TE, Benneyan JC, et al. J Patient Saf. 2022;18:e1142-e1149.
The opioid epidemic has prompted national and institutional guidelines for safe opioid prescribing. This paper describes the development, implementation, and sustainment of a toolkit for safer opioid prescribing for chronic pain in primary care. The authors describe organizational, technical, and external barriers to implementation along with attempted solutions and their effects. The toolkit is available as supplemental material.

Rockville, MD: Agency for Healthcare Research and Quality; October 2022.

Inappropriate antibiotic prescribing is associated with increased risk potential. This toolkit assists in simplifying the antibiotic decision-making process. It is organized around a four-point decision aide and contains resources on using a stewardship program, communicating about prescribing and applying best practices for common infectious diseases.