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 3623 Results

The impact of language barriers on patient care: a pharmacy perspective.

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Patel J. PM Healthcare Journal. Spring 2023(4):5-18.

Language discordance is known to degrade medication safety. The article discusses an examination of English pharmacists’ reactions and responses to language barriers with patients. The results highlight the need for improved training and support for pharmacists to effectively dispense medications and counsel patients with whom they don’t share a common language.

Actions to renew focus on safety culture.

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Salvon-Harman J. Healthcare Executive. 2023;39(3):48-49.

A strong safety work environment is core to reliable care delivery and staff wellbeing. This article discusses how leadership should listen broadly, embody accountability, support disclosure, and build trust to build a robust safety culture.

Analysis of reported suicide safety events among veterans who received treatment through Department of Veterans Affairs-contracted community care.

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Riblet NB, Soncrant C, Mills PD, et al. Mil Med. 2023;Epub Mar 31.

Patient suicide is a sentinel event, and suicide among veterans has gained attention. In this retrospective analysis of suicide-related events reported to the Veterans Health Administration (VHA) National Center for Patient Safety between January 2018 and June 2022, researchers found that deficiencies in mental health treatment, communication challenges, and unsafe environments were the most common contributors to suicide-related events.

Interorganizational health information exchange-related patient safety incidents: a descriptive register-based qualitative study.

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Hyvämäki P, Sneck S, Meriläinen M, et al. Int J Med Inform. 2023;174:105045.

Insufficient or incorrect transfer of patient information, whether caused by human or organizational factors, can result in adverse events during transitions of care. This study used four years of incident reports to identify the types, causes, and consequences of health information exchange- (HIE) related patient safety incidents in emergency care, (ED) emergency medical services (EMS), or home care. The two main kinds of HIE-related incidents were (1) inadequate documentation and inadequate use of information (e.g., deficiencies in content), and (2) causes related to the health professional or organization; consequences were adverse events or additional actions to prevent, avoid, and correct adverse events.

Medication safety event reporting: factors that contribute to safety events during times of organizational stress.

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Cohen TN, Berdahl CT, Coleman BL, et al. J Nurs Care Qual. 2023;Epub May 9.

Institutional error and near-miss reporting helps identify systemic weaknesses and areas for improvement. COVID-19 presented a unique environment to study error reporting during organizationally stressful times. In this study, incident reports of medication errors or near misses during a COVID-19 surge were analyzed. Skill-based (e.g., forgetting to administer a dose) and communication errors were the most common medication safety events.

Adverse patient safety events during the COVID epidemic.

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Yackel EE, Knowles RS, Jones CM, et al. J Patient Saf. 2023;Epub May 1.

The COVID-19 pandemic dramatically changed healthcare delivery and exacerbated threats to patient safety. Using Veterans Health Administration (VHA) National Center for Patient Safety data, this retrospective study characterized patient safety events related to COVID-19 occurring between March 2020 and February 2021. Delays in care and exposure to COVID-19 were the most common events and confusion over procedures, missed care, and failure to identify COVID-positive patients before exposures were the most common contributing factors.

Effects of a multimodal transitional care intervention in patients at high risk of readmission: the TARGET-READ randomized clinical trial.

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Donzé JD, John G, Genné D, et al. JAMA Internal Med. 2023;Epub May 1.

Adverse events and unplanned, preventable readmissions occur in approximately 20% of patients following discharge from the hospital. This randomized clinical trial compares standard care with a multi-modal discharge intervention targeting patients at highest risk of unplanned readmission. Despite the intensity of the intervention, there was no statistical difference between that intensity and the standard of care in unplanned readmission, time to readmission, or death.

The family's contribution to patient safety.

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Correia T, Martins MM, Barroso F, et al. Nurs Rep. 2023;13:634-643.

Family involvement in care can have mixed results for patient safety. Interviews with nurses show seven ways families can hinder safety and ten ways they improve safety. The risk of infection was the greatest safety threat and being a unique source of information helped increase patient safety. Interestingly, "greater workload for nurses" was identified as a facilitator of patient safety, potentially, as it lowered the stress experienced by the nurse and increased family satisfaction and positive involvement.

Factors contributing to preventing operating room "never events": a machine learning analysis.

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Arad D, Rosenfeld A, Magnezi R. Patient Saf Surg. 2023;17:6.

Surgical never events are rare but devastating for patients. Using machine learning, this study identified 24 contributing factors to two types of surgical never events - wrong site surgery and retained items. Communication, the number and type of staff present, and the type and length of surgery were identified contributing factors.

Curated Libraries

Implementation of Patient Safety Projects Curated Library

May 4, 2023

The implementation of effective patient safety initiatives is challenging due to the complexity of the health care environment. This curated library shares resources summarizing overarching ideas and strategies that can aid in successful program execution, establishment, and sustainability.

Delays in care during the COVID-19 pandemic in the Veterans Health Administration.

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Mills PD, Louis RP, Yackel E. J Healthc Qual. 2023;Epub Apr 11.

Changes in healthcare delivery due to the COVID-19 pandemic resulted in delays in care that can lead to patient harm. In this study using patient safety event data submitted to the VHA National Center of Patient Safety, researchers identified healthcare delays involving laboratory results, treatment and interventional procedures, and diagnosis.

More than algorithms: an analysis of safety events involving ML-enabled medical devices reported to the FDA.

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Lyell D, Wang Y, Coiera E, et al. J Am Med Inform Assoc. 2023;Epub Apr 18.

Patients and healthcare providers rely on devices that use artificial intelligence or machine learning in diagnostics, treatment, and monitoring. This study utilizes adverse event reports submitted to the FDA's Manufacturer and Use Facility Device Experience (MAUDE) database for machine learning-enabled devices. Mammography was implicated in 69% of reports, and the majority were near-miss events.

Uptake of pharmacist recommendations by patients after discharge: implementation study of a patient-centered medicines review service.

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Basger BJ, Moles RJ, Chen TF. BMC Geriatr. 2023;23:183.

Potentially inappropriate medications (PIM) and polypharmacy, defined as taking 5 or more medications, can increase the risk of hospitalization and other adverse events for older adults. This article describes the implementation and success of a patient-centered medication review conducted at the time of hospital discharge. Nearly all patients followed up with their general practitioner on the pharmacist’s recommendations and approximately three-quarters were implemented. Including the patient and/or caregiver was a key component of the intervention.

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.

Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes.

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WebM&M Case April 26, 2023

This Spotlight Case highlights two cases of falls in older patients in nursing homes. The commentary discusses how risk factors for falls should be considered in care planning and approaches to fall prevention in long-term care settings.

The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department.

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WebM&M Case April 26, 2023

This case involves a procedural sedation error in a 3-year-old patient who presented to the Emergency Department with a left posterior hip dislocation. The commentary summarizes the indications and risks of procedural sedation in non-surgical settings and highlights the value of implementing system-wide safety protocols and practices to prevent medication administration errors during high-risk procedures.

Patient safety tools for primary care.

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Domdera J. Fam Pract Manag. 2023;30(2):24-28.

A large segment of patients receives outpatient care. This commentary suggests that high-reliability concepts be applied in the primary care environment to reduce the potential for mistakes and patient harm. The author shares tools to address communication and care coordination problems.

Strengthening open disclosure after incidents in maternity care: a realist synthesis of international research evidence.

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Adams M, Hartley J, Sanford N, et al. BMC Health Serv Res. 2023;23:285.

Patients and families expect full, timely disclosure after incidents. This realist synthesis examines research on patient disclosure to inform what is required to strengthen disclosure in maternity care. Five key themes were identified, including meaningful acknowledgment of harm and opportunities for patients and families to be involved in the follow-up.

Preventing home medication errors.

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Shaikh U, van der List L, Blumberg D. Kids Considered. March 27, 2023.

Medication administration at home can be problematic especially for parents caring for children. This podcast highlights common reasons for medication mistakes at home and how they can be avoided. Simple steps such as not using regular spoons as methods of delivering liquid medications are highlighted.

What works in medication reconciliation: an on-treatment and site analysis of the MARQUIS2 study.

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Schnipper JL, Reyes Nieva H, Yoon CS, et al. BMJ Qual Saf. 2023;Epub Mar 22.

Implementing successful interventions to support effective medication reconciliation is an ongoing challenge. The MARQUIS2 study examined whether system- and patient-level interventions plus physician mentors can improve medication reconciliation and reduce medication discrepancies. This analysis based on patient exposure in the MARQUIS2 study found that patient receipt of a best possible medication history (BPMH) in the emergency department and medication reconciliation at admission and discharge were associated with the largest reductions in medication discrepancy rates.

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