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 280 Results

Validation of a reduced set of high-performance triggers for identifying patient safety incidents with harm in primary care.

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Garzón González G, Alonso Safont T, Conejos Míquel D, et al. J Patient Saf. 2023;19:508-516.

Retrospective chart review is the standard for estimating prevalence of adverse events manual review of the electronic health record (EHR) is resource intensive. This study describes the construction and validation of electronic trigger set, TriggerPrim, to rapidly identify charts with potential adverse events in primary care. The resulting set has five triggers: ≥3 appointments in a week at the PC center, hospital admission, hospital emergency department visit, prescription of major opioids, and chronic benzodiazepine treatment in patients 75 years or older. Use of TriggerPrim reduced time in the EHR by half.

Identifying contributing factors associated with dental adverse events through a pragmatic electronic health record-based root cause analysis.

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Kalenderian E, Bangar S, Yansane A, et al. J Patient Saf. 2023;19:305-312.

Understanding factors that contribute to adverse events (AE) is key to preventing them from recurring. This study used an electronic trigger tool to identify potential AE in two dental practices. Of 439 charts reviewed, 13% contained at least one AE. The most common AE was post-procedural pain; the expert panel reported 21% of those AEs were preventable. Person-related factors (e.g., supervision, fatigue) were the most common contributing factors.

Frequency, type, and degree of potential harm of adverse safety events among pediatric emergency medical services encounters.

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Cicero MX, Baird J, Brown L, et al. Prehosp Emerg Care. 2023;Epub Sep 12.

The pediatric population faces unique challenges in the prehospital setting. This prospective chart review study classified adverse safety events (ASE) of pediatric patients at 15 emergency medical services (EMS) agencies. More than 20% of encounters contained at least one ASE, although most were unlikely to cause harm (e.g., missed documentation).

Adverse drug events caused by three high-risk drug-drug interactions in patients admitted to intensive care units: a multicentre retrospective observational study.

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Klopotowska JE, Leopold J‐H, Bakker T, et al. Br J Clin Pharmacol. 2023;Epub Aug 11.

Identifying and preventing drug-drug interactions (DDI) is critical to patient safety, but the usual method of detecting DDI and other errors - manual chart review - is resource intensive. This study describes the use of an e-trigger to pre-select charts for review that are more likely to include one of three DDIs, thus reducing the overall number of charts needing review. Two of the DDI e-triggers had high positive predictive values (0.76 and 0.57), demonstrating that e-triggers can be a useful method to pre-selecting charts for manual review.

Community validation of an approach to detect delayed diagnosis of appendicitis in big databases.

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Michelson KA, McGarghan FLE, Waltzman ML, et al. Hosp Pediatr. 2023;13:e170-e174.

Trigger tools are commonly used to detect adverse events and identify areas for safety improvement. This study found that trigger tools using electronic health record-based data can accurately identify delayed diagnosis of appendicitis in pediatric patients in community emergency department (ED) settings.

Automated search methods for identifying wrong patient order entry-a scoping review.

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Garrod M, Fox A, Rutter P. JAMIA Open. 2023;6:ooad057.

Understanding causes of wrong-patient order entry (WPOE) can help develop interventions to reduce those medication errors. This review summarizes how organizations and providers identify WPOE, what data are being captured, and causes. The most common organizational detection method is the retract-and-reorder method whereby a medication order is cancelled then reordered on a different patient within a specified period of time. There was minimal data on how providers detect their own WPOE errors. Technology and physician workload were identified as contributors to WPOE.

Comparing rates of adverse events detected in incident reporting and the Global Trigger Tool: a systematic review.

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Hibbert PD, Molloy CJ, Schultz TJ, et al. Int J Qual Health Care. 2023;35:mzad056.

Accurate and reliable detection and measurement of adverse events remains challenging. This systematic review examined the difference in adverse events detected using the Global Trigger Tool compared to those detected via incident reporting systems. In 12 of the 14 included studies, less than 10% of adverse events detected using the Global Trigger Tool were also found in corresponding incident reporting systems. The authors of the review emphasize the importance of using multiple approaches and sources of patient safety data to enhance adverse event detection.

Adverse Events Toolkit: Medical Record Review Methodology.

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Maxwell A. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; July 2023. Report no. OEI-06-21-00030.

Medical record review is a primary tactic to identify health care actions that contribute to patient harm. This report discusses the review process used in the 2018 report Adverse Events in Hospitals: A Quarter of Medicare Patients Experienced Harm to illustrate a successful review process for use by clinicians and researchers. It is a companion toolkit to the Clinical Guidance for Identifying Harm publication.

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

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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.

Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units

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Perspective on Safety April 26, 2023

This piece discusses surveillance monitoring of patients in low-acuity units of the hospital to prevent failure to rescue events, its difference from high-acuity continuous monitoring, and its potential applications in other settings.

In Conversation with Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring

Drs. Susan McGrath and George Blike discuss surveillance monitoring and its challenges and opportunities.

Effect of a Veterans Health Administration mandate to case review patients with opioid prescriptions on mortality among patients with opioid use disorder: a secondary analysis of the STORM randomized control trial.

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Auty SG, Barr KD, Frakt AB, et al. Addiction. 2023;118:870-879.

To combat serious adverse events (SAE) and suicide among veterans with opioid use disorder (OUD), the Veterans Health Administration (VHA) implemented the Stratification Tool for Opioid Risk Mitigation (STORM) in all VHA facilities. Patients identified as high-risk for SAE by STORM received a mandatory case review. This study focuses on high-risk patients with a new OUD diagnosis. Mandatory case review increased the odds of all-cause mortality, but not SAE. Patients whose opioids were discontinued after case review showed even higher odds of mortality.

Technology as a Tool for Improving Patient Safety

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Perspective on Safety March 29, 2023

In the past several decades, technological advances have opened new possibilities for improving patient safety. Using technology to digitize healthcare processes has the potential to increase standardization and efficiency of clinical workflows and to reduce errors and cost across all healthcare settings.¹ However, if technological approaches are designed or implemented poorly, the burden on clinicians can increase. For example, overburdened clinicians can experience alert fatigue and fail to respond to notifications. This can lead to more medical errors.

Electronic health record-based prediction models for in-hospital adverse drug event diagnosis or prognosis: a systematic review.

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Yasrebi-de Kom IAR, Dongelmans DA, de Keizer NF, et al. J Am Med Inform Assoc. 2023;30:978-988.

Prediction models are increasingly used in healthcare to identify potential patient safety events. This systematic review including 25 articles identified several challenges related to electronic health record (EHR)-based prediction models for adverse drug event diagnosis or prognosis, including adherence to reporting standards, use of best practices to develop and validate prediction models, and absence of causal prediction modeling.

Reducing hospital harm: establishing a command centre to foster situational awareness.

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Patient Safety Innovation March 29, 2023

Situational awareness during complex care events, such as clinical deterioration, medication administration, or the admission process, is an important component of teamwork and high reliability.

The accuracy of the Global Trigger Tool is higher for the identification of adverse events of greater harm: a diagnostic test study.

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Moraes SM, Ferrari TCA, Beleigoli A. Int J Qual Health Care. 2023;34:mzad005.

The IHI Global Trigger Tool (GTT) is used to detect adverse events (AE) in hospitalized patients, but studies have shown variability in the types and rates of errors detected. In this study, researchers aimed to determine the accuracy of the GTT through a diagnostic test study. The GTT showed satisfactory sensitivity, specificity, and global accuracy for AE detection, but performed better when minor harm AEs were excluded.

Automated capture of intraoperative adverse events using artificial intelligence: a systematic review and meta-analysis.

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Eppler MB, Sayegh AS, Maas M, et al. J Clin Med. 2023;12:1687.

Real-time use of artificial intelligence in the operating room allows surgeons to avoid or immediately address intraoperative adverse events. This review summarizes 13 articles published since 2010 that report on the use of artificial intelligence to predict intraoperative adverse events. Most studies used video and more than half were intended to detect bleeding.

Near-miss events detected using the emergency department trigger tool.

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Griffey RT, Schneider RM, Todorov AA. J Patient Saf. 2023;19:59-66.

Near-miss incidents present useful learning opportunities but frequently go unreported. This study used a computerized trigger tool to identify near-miss incidents in the emergency department (ED). Results show approximately 23% of ED visits during the 13-month study period included a near-miss incident. This analysis suggests computerized trigger tools can be useful to identify near misses that otherwise go unreported.

Using automated methods to detect safety problems with health information technology: a scoping review.

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Surian D, Wang Y, Coiera E, et al. J Am Med Inform Assoc. 2022;30:382-392.

Health information technology (HIT), such as electronic health records (EHRs) or computerized provider order entry (CPOE) systems, are important approaches to improving safety. This scoping review of 45 articles found that machine learning and statistical modeling are the most commonly used automated, HIT-based methods for early detection of safety threats. Machine learning was often used to detect errors occurring in laboratory test results, prescriptions, and patient records. Statistical modeling was used to detect issues with clinical decision support systems.

A customized triggers program: a children's hospital's experience in improving trigger usability.

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Reinhart RM, Safari-Ferra P, Badh R, et al. Pediatrics. 2023;151:e2022056452.

Trigger tools are widely used for detecting potential adverse events among adult and pediatric inpatients. This article describes the development of a pediatric triggers program that can identify potential adverse events in near real-time to facilitate appropriate preventative measures. The tool includes criteria from the IHI Global Trigger Tool as well as novel triggers (such as pain reassessment time, hospital readmissions, and suspected sepsis). The trigger team created a process for linking triggers to the organizational incident reporting system based on specific criteria (to reduce false-positive reports). The trigger team is continuously developing and refining triggers based on stakeholder input.

A structured approach to EHR surveillance of diagnostic error in acute care: an exploratory analysis of two institutionally-defined case cohorts.

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Malik MA, Motta-Calderon D, Piniella N, et al. Diagnosis (Berl). 2022;9:446-457.

Structured tools are increasingly used to identify diagnostic errors and related harms using electronic health record data. In this study, researchers compared the performance of two validated tools (Safer Dx and the DEER taxonomy) to identify diagnostic errors among patients with preventable or non-preventable deaths. Findings indicate that diagnostic errors and diagnostic process failures contributing to death were higher in preventable deaths (56%) but were also present in non-preventable deaths (17%).

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