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 62 Results

Supporting nurses in acute and emergency care settings to speak up.

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Clarke-Romain B. Emerg Nurse. 2023;Epub Sep 19.

Delays in raising concerns in acute or emergency care can have tragic consequences. This commentary uses a case study to highlight barriers to speaking up and evidence-based tools nurses can use such as the CUS Tool and two-challenge rule. Training all healthcare staff in communication techniques can encourage speaking up and respectful responses.

A scoping review of clinical handover mnemonic devices.

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Yung AHW, Pak CS, Watson B. Int J Qual Health Care. 2023;35:mzad065.

Cognitive aids such as mnemonics can help improve process reliability and promote patient safety. Based on an initial scoping review, this article describes a proposed taxonomy for clinical handoff mnemonics and their clinical processes and functions, which could help clinical teams design handoff mnemonics that best fit their workplace.

A Double “Never Event”: Wrong Patient and Wrong Side.

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WebM&M Case September 27, 2023

This case highlights two “never events” involving the same patient. A first-year orthopedic surgery resident was consulted to aspirate fluid from the left ankle of a patient in the intensive care unit. The resident, accompanied by a second resident, approached the wrong patient and inserted the needle into the patient’s right ankle. At this point, a third resident entered the room and stated that it was the incorrect patient. The commentary highlights the importance of a proper time out and approaches to improve communication among all members of the care team.

Prolonged DKA in Pregnancy: A Case of Communication Breakdown.

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WebM&M Case August 30, 2023

A 31-year-old pregnant patient with type 1 diabetes on an insulin pump was hospitalized for euglycemic diabetic ketoacidosis (DKA). She was treated for dehydration and vomiting, but not aggressively enough, and her metabolic acidosis worsened over several days. The primary team hesitated to prescribe medications safe in pregnancy and delayed reaching out to the Maternal Fetal Medicine (MFM) consultant, who made recommendations but did not ensure that the primary team received and understood the information.

Patient handoffs and multi-specialty trainee perspectives across an institution: informing recommendations for health systems and an expanded conceptual framework for handoffs.

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Williams SR, Sebok-Syer SS, Caretta-Weyer H, et al. BMC Med Educ. 2023;23:434.

Standardizing handoff training in residency programs can lead to safer, more effective handoffs. Researchers surveyed a sample of 687 residents and fellows from over 30 specialties about handoff training perspectives. Participants reported wide variability in handoff content and identified important aspects of handoff training (critical handoff elements, the impact of systems-level factors, impact of the handoff on providers and patients, professional duty, and addressing blame or guilt related to poor handoff experiences).

A Complicated Course: Severe Alcohol Withdrawal with Dexmedetomidine Infusion.

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WebM&M Case July 31, 2023

This case describes a 65-year-old man with alcohol use disorder who presented to a hospital 36 hours after his last alcoholic drink and was found to be in severe alcohol withdrawal. The patient’s Clinical Institute Withdrawal Assessment (CIWA) score was very high, indicating signs and symptoms of severe alcohol withdrawal. He was treated with symptom-triggered dosing of benzodiazepines utilizing the CIWA protocol and dexmedetomidine continuous infusion.

Statewide perinatal quality improvement, teamwork, and communication activities in Oklahoma and Texas.

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Stierman EK, O'Brien BT, Stagg J, et al. Qual Manag Health Care. 2023;32:177-188.

Maternal morbidity and mortality remain a significant problem in U.S. health care. This article describes Texas and Oklahoma’s adoption of a perinatal quality improvement initiative, including the implementation of the Alliance for Innovation of Maternal Health (AIM) patient safety bundles and use of teamwork and communication tools in obstetric units. Findings suggest that adoption of initiative components varies across obstetric units; the majority of units had standardized processes for serious events (obstetric hemorrhage, massive transfusion, severe hypertension) but fewer units offered regular training on effective teamwork and communication for their staff.

Perioperative handoff enhancement opportunities through technology and artificial intelligence: a narrative review.

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Sparling J, Hong Mershon B, Abraham J. Jt Comm J Qual Patient Saf. 2023;49:410-421.

Multiple handoffs can occur during perioperative care, which can increase the risk for errors and patient harm. This narrative review summarizes research on the benefits, limitations, and implementation challenges of electronic tools for perioperative handoffs and the role of artificial intelligence (AI) and machine learning (ML) in perioperative care.

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;45:242-253.

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.

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.

We are not there yet: a qualitative system probing study of a hospital rapid response system.

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Olsen SL, Søreide E, Hansen BS. J Patient Saf. 2022;18:717-721.

Rapid response systems (RRS) are widely used to identify signs of rapid deterioration among hospitalized patients. Using in situ simulation, researchers identified obstacles to effective RRS execution, including inconsistent education and documentation, lack of interpersonal trust, and low psychological safety.

The Top Six: standardized safety practices in U.S. Army Medical Department treatment facilities worldwide.

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Hartstein B, Munante M, Toor PA. NEJM Catalyst. 2022;3:e1-e20.

High-reliability organizations (HROs) are able to “manage the unexpected” while operating under challenging conditions. This article describes the U.S. Medical Department’s systemwide rollout of the Top Six HRO communication practices. The authors summarize how the Top Six campaign was developed and discuss the implementation of six systemwide initiatives to increase reliability – (1) daily safety briefings; (2) safety leadership rounds; (3) unit-based huddles; (4) Situation Background Assessment Recommendation (SBAR) for communication; (5) briefs and debriefs for surgical cases; and (6) Universal Protocol before every procedure.

Proceed with reasonable care: when legal principles inform training to prevent harm during the childbirth.

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Petrovic M, Nicholls J, Siassakos D. Best Pract Res Clin Obstet Gynaecol. 2022;80:105-113.

Improving safe maternal care is an ongoing patient safety priority. This article outlines training strategies for providing safe obstetric care and improving communication among providers and patients.

Adverse events during intrahospital transport of critically ill patients: a systematic review and meta-analysis.

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Murata M, Nakagawa N, Kawasaki T, et al. Am J Emerg Med. 2022;52:13-19.

Transporting critically ill patients within a hospital (e.g., to radiology for diagnostic procedures) is necessary but also poses safety threats. The authors conducted a systematic review and meta-analysis of all types of adverse events, critical or life-threatening adverse events, and death occurring during intra-hospital transport. Results indicate that adverse events can occur in intra-hospital transport, and that frequency of critical adverse events and death are low.

Can SBAR be implemented with high fidelity and does it improve communication between healthcare workers? A systematic review.

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Lo L, Rotteau L, Shojania KG. BMJ Open. 2021;11:e055247.

Situation, Background, Assessment, Recommendation (SBAR) is a mnemonic technique used to avoid communication failures during handoffs. This systematic review found that fidelity with SBAR is highest in classroom settings, but that studies in clinical contexts either did not achieve sufficient improvements in fidelity or did not assess fidelity.

Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery.

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WebM&M Case November 25, 2020

After a failed induction at 36 weeks, a 26-year-old woman underwent cesarean delivery which was complicated by significant postpartum hemorrhage. The next day, the patient complained of severe perineal and abdominal pain, which the obstetric team attributed to prolonged pushing during labor. The team was primarily concerned about hypotension, which was thought to be due to hypovolemia from peri-operative blood loss. After several hours, the patient was transferred to the medical intensive care unit (ICU) with persistent hypotension and severe abdominal and perineal pain. She underwent surge

Implicit Biases, Interprofessional Communication, and Power Dynamics

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WebM&M Case April 29, 2020

A patient with progressive mixed respiratory failure was admitted to the step-down unit despite the physician team’s request to send the patient to the ICU. The case reveals issues of power dynamics, hierarchies, and implicit bias as young female physicians interact with experienced male members in the interdisciplinary team.

Complications of ECMO During Transport

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WebM&M Case April 29, 2020

A 54-year old women with chronic obstructive pulmonary disease was admitted for chronic respiratory failure. Due to severe hypoxemia, she was intubated, mechanically ventilated and required extracorporeal membrane oxygenation (ECMO). During the hospitalization, she developed clotting problems, which necessitated transfer to the operating room to change one of the ECMO components. On the way back to the intensive care unit, a piece of equipment became snagged on the elevator door and the system alarmed.

Interventions to improve team effectiveness within health care: a systematic review of the past decade.

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Buljac-Samardzic M, Doekhie KD, van Wijngaarden JDH. Hum Resourc Health. 2020;18.

This systematic review is an update of prior research characterizing the evidence base on team effectiveness in healthcare organizations. The review analyzed 297 publications focused on three types of interventions: (1) training, including crew resource management, TeamSTEPPS and simulations, (2) tools, including SBARs and checklists, and (3) organizational (re)designs, which involves intervening in structures which lead to improved team functioning (such as changing the physical environment or altering roles/responsibilities). The authors found that existing evidence base is limited to certain interventions, settings (primarily acute care), and outcomes (primarily non-technical skills). The authors call for more longitudinal research, particularly examining team functioning outside the hospital setting.

Communication Between Clinicians

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Patient Safety Primer September 7, 2019

Clear and high-quality communication between all staff involved in caring for a patient is essential in order to achieve situational awareness. Breakdowns in communication are closely tied to preventable adverse events in hospitalized and ambulatory patients.

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