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 147 Results

Healthcare Failure Mode and Effects Analysis.

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ECRI and the Institute for Safe Medication Practices. November 14, 2023, 12:00-5:00 PM (eastern).

Failure mode and effect analysis (FMEA) is a proactive method to identify risks at each step in the process. Attendees of this training will learn how and why healthcare FMEA is performed, and apply their learning to case studies.

Implementing patient safety and quality improvement in dermatology.

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Marsch A, Khodosh R, Porter M, et al. J Am Acad Dermatol. 2023;89(4):641-54; 57-67.

Patient safety in dermatology has received increasing attention over the past ten years. Part 1 of this series provides examples of patient safety concerns in dermatology (e.g., medication errors, teledermatology) and how key patient safety concepts such as safety culture and root cause analysis can be applied in dermatology settings. Part 2 of this series applies three quality improvement frameworks (LEAN, Six Sigma, and IHI-QI) can be used to improve the quality and safety of dermatology practice.

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.

Identifying failure modes in telemedicine: an instructional needs assessment.

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Monkman H, Kuziemsky C, Homco J, et al. Stud Health Technol Inform. 2023;304:39-43.

Implementation challenges can hinder the safety of telehealth. In this study, medical students used Healthcare Failure Modes and Effect Analysis to identify the causes of failures in telehealth and potential prevention strategies. Four categories of failures were identified: technical issues, patient safety, communication, and social and structural determinants.

Using failure mode and effect analysis to identify potential failures in a psychiatric hospital emergency department.

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Gur-Arieh S, Mendlovic S, Rozenblum R, et al. J Patient Saf. 2023;19:362-368.

Failure mode and effect analysis (FMEA) is a common way to identify error risk. In this study, FMEA was used in a psychiatric hospital emergency department (ED) to identify potential failures. FMEA was completed by two groups, ED staff and non-ED staff, to determine if a multi-professional team could be used for the FMEA process. The groups’ ratings were very similar, indicating a multi-professional team can effectively complete an FMEA.

Improving Diagnostic Safety and Quality

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Perspective on Safety April 26, 2023

Throughout 2022, AHRQ PSNet has shared research that elucidates the complex nature of misdiagnosis and diagnostic safety. This Year in Review explores recent work in diagnostic safety and ways that greater safety may be promoted using tools developed to improve diagnostic practices.

Adopting high reliability organization principles to lead a large scale clinical transformation.

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Pozzobon LD, Lam J, Chimonides E, et al. Healthc Manage Forum. 2023;36:241-245.

High-reliability organizations are able to achieve safety despite organizational changes or other hazardous conditions. This article describes the implementation of a new electronic health record (EHR) system at one academic health system in Canada and provides examples of how high-reliability principles informed activities to prevent patient harm during this organizational change.

Evaluating patient identification practices during intrahospital transfers: a human factors approach.

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Suclupe S, Kitchin J, Sivalingam R, et al. J Patient Saf. 2023;19:117-127.

Patient identification mistakes can have serious consequences. Using the Systems Engineering for Patient Safety (SEIPS) framework, this qualitative study explored systems factors contributing to patient identification errors during intrahospital transfers. The authors found that patient identification was not completed according to hospital policy during any of the 60 observed patient transfer handoffs. Miscommunication and lack of key patient information were common factors contributing to identification errors.

Using Failure Mode, Effect and Criticality Analysis to improve safety in the cancer treatment prescription and administration process.

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Buja A, De Luca G, Ottolitri K, et al. J Pharm Policy Pract. 2023;16:9.

Failure Mode, Effect and Criticality Analysis (FMECA) is a prospective method for identifying and preventing potential error risks. Using FMECA, public health medical residents calculated a Risk Priority Number (RPN), or criticality, for each possible failure mode in cancer treatment prescription and administration. Each phase of the cancer treatment process had at least one critical step identified, and actions were developed to reduce the likelihood of the error occurring and/or to increase the likelihood of the error being detected.

Risk assessment of the acute stroke diagnostic process using failure modes, effects, and criticality analysis.

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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.

Fellowships and Mentorships Program.

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Institute for Safe Medication Practices.

These educational programs with the Institute for Safe Medication Practices (ISMP) are for clinicians who wish to expand their practical knowledge of medication error prevention. The application process for the 2023-2024 fellowships will close May 16, 2023.

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Diagnostic Safety

October 10, 2022

Selected PSNet materials for a general safety audience focusing on improvements in the diagnostic process and the strategies that support them to prevent diagnostic errors from harming patients.

Positive approaches to safety: learning from what we do well.

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Plunkett A, Plunkett E. Paediatr Anaesth. 2022;32:1223-1229.

Safety-I focuses on identifying factors that contribute to incidents or errors. Safety-II seeks to understand and learn from the many cases where things go right, including ordinary events, and emphasizes adjustments and adaptations to achieve safe outcomes. This commentary describes Safety-II and complementary positive strategies of patient safety, such as exnovation, appreciative inquiry, learning from excellence, and positive deviance.

Combined proactive risk assessment: unifying proactive and reactive risk assessment techniques in health care.

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Bender JA, Kulju S, Soncrant C. Jt Comm J Qual Patient Saf. 2022;48:326-334.

Healthcare organizations use multiple proactive and reactive methods of investigating and preventing adverse events. This study combined proactive and reactive risk assessments into a Combined Proactive Risk Assessment (CPRA) to identify risks not detected by one method on its own. The four steps of CPRA are illustrated using the example of outpatient blood draws in the Veterans Health Administration.

Strategies and Approaches for Investigating Patient Safety Events

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Patient Safety Primer March 30, 2022

This primer provides a broad overview of three widely used tools for investigating and responding to patient safety events and near misses. Tools covered in this primer are incident reporting systems, Root Cause Analysis (RCA), and Failure Modes and Effects Analysis (FMEA). These tools have been used in high-risk industries and occupations such as aviation, manufacturing, nuclear power, and the military and have been adapted for use in enhancing patient safety in healthcare settings over the past two decades.

Reliability, uncertainty and the management of error: new perspectives in the COVID-19 era.

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Schulman PR. J Contingencies Crisis Manage. 2022;30:92-101.

High reliability organizations (HROs) are those that operate in highly complex domains, such as aviation, with no or very few significant errors. This commentary describes the relationship between error and uncertainty in HROs using the increased uncertainties brought on by the COVID-19 pandemic as an example.

Preventing and mitigating radiology system failures: a guide to disaster planning.

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Gibney BT, Roberts JM, D'Ortenzio RM, et al. RadioGraphics. 2021;41:2111-2126.

Hospitals are increasingly creating and updating their emergency disaster response plans. This guide assists hospital executives, quality & safety professionals, and risk managers by assessing potential hazards or failures in radiology departments in the event of disaster. Disaster planning tools, checklists, and other recommendations are described.

A simulation systems testing program using HFMEA methodology can effectively identify and mitigate latent safety threats for a new on-site helipad.

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Holmes J, Chipman M, Barbour T, et al. Jt Comm J Qual Patient Saf. 2022;48:12-24.

Air medical transport carries unique patient safety risks. In this study, researchers used simulation training and healthcare failure mode and effect analysis (HFMEA) to identify latent safety threats related to patient transport via helicopter. This approach identified 31 latent safety threats (18 were deemed critical) related to care coordination, facilities, equipment, and devices.

Using failure mode and effects analysis to increase patient safety in cancer chemotherapy.

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Weber L, Schulze I, Jaehde U. Res Social Adm Pharm. 2022;18:3386-3393.

Chemotherapy administration errors can result in serious patient harm. Using failure mode and effects analysis (FMEA), researchers identified potential failures related to the medication process for intravenous chemotherapy. Common failures included incorrect patient information, non-standardized chemotherapy protocols, and problems related to supportive therapy.

Healthcare failure mode and effect analysis in the chemotherapy preparation process.

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Pueyo-López C, Sánchez-Cuervo M, Vélez-Díaz-Pallarés M, et al. J Oncol Pharm Pract. 2021;27:1588-1595.

Researchers in this study used healthcare failure mode and effect analysis (HFMEA) to identify and reduce errors during chemotherapy preparation. Nine potential failure modes were identified – wrong label, drug, dose, solvent, or volume; non-sterile preparation; incomplete control; improper packaging or labeling, and; break or spill – and the potential causes and effects. Potential approaches to reduce these failure modes include updating the Standard Operating Procedures (SOPs), implementing a bar code system, and using a weight-based control system.

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