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 251 Results

Anesthesia workspaces for safe medication practices: design guidelines.

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MohammadiGorji S, Joseph A, Mihandoust S, et al. HERD. 2023;Epub Aug 8.

Well-designed workspaces minimize disruptions and distractions. This review and study describes several important ways to improve the anesthesia workspace in the operating room. Recommendations include demarcating an anesthesia zone with adequate space for equipment and storage and that restricts unnecessary staff travel into and through the zone. Each recommendation includes an illustrative diagram, explains its importance, and offers methods to achieve it.

Technology, Education and Safety

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Arnal-Velasco, D, ed. Curr Opin Anaesthesiol. 2023;36(6):649-705.

Adoption of new ideas is necessary to create safety in the perioperative environment. This collection of reviews illustrates relationships and tensions between technology, human factors and safety management that create the sociotechnical system within which technology is used to deliver anesthesia. Topics covered include artificial intelligence, decision making and perioperative deterioration.

Alarm burden and the nursing care environment: a 213-hospital cross-sectional study.

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Ruppel H, Dougherty M, Bonafide CP, et al. BMJ Open Qual. 2023;12:e002342.

Alarm fatigue can lead to desensitization to safety alerts and threaten patient safety. In this survey of 3,986 registered nurses, the majority (83%) reported alarm fatigue and over half (55%) experienced a situation where an alarm went unchecked despite a patient requiring urgent attention. The researchers found that alarm burden was more common among respondents who rated their hospital’s safety as poor or reported poor work environments.

On Patient Safety.

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Rickert J, Järvinen TLN, Lee MJ, et al. Clin Orthop Relat Res. 2013-2023.

This quarterly commentary explores a wide range of subjects associated with patient safety, such as the impact of disruptive behavior on teams, the value of apologies, and safety challenges inherent in clinician strike actions. Older materials are available online for free.

Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose.

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WebM&M Case October 31, 2023

A 2-year-old girl presented to the emergency department (ED) with joint swelling and rash following an upper respiratory infection. After receiving treatment and being discharged with a diagnosis of allergic urticaria, she returned the following day with worsening symptoms. Suspecting an allergic reaction to amoxicillin, the ED team prepared to administer methylprednisolone. However, the ED intake technician erroneously switched the patient’s height and weight in the electronic health record (EHR), resulting in an excessive dose being ordered and dispensed.

Improving care safety by characterizing task interruptions during interactions between healthcare professionals: an observational study.

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Teigné D, Cazet L, Birgand G, et al. Int J Qual Health Care. 2023;35:mzad069.

Interruptions and distractions can diminish the quality and safety of care and lead to preventable medical errors. This observational study characterized interruptions affecting 23 care teams working in medical or surgical specialties across 17 sites in France. The researchers estimated that, on average, professionals were interrupted 10.5 times per hour, and that 57% of interruptions were avoidable.

California pharmacies are making millions of mistakes. They’re fighting to keep that secret.

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Peterson M. Los Angeles Times. September 5, 2023.

Safe practice in community pharmacy is challenged by production pressure, workforce shortages, and multitasking. This story examined the mistakes made at major retail pharmacy chains in California. It provides examples perpetrated across the industry to target universal areas of needed improvement and potential strategies to address them.

Video review of simulated pediatric cardiac arrest to identify errors/latent safety threats: a mixed methods study.

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Garcia-Jorda D, Nikitovic D, Gilfoyle E. Simul Healthc. 2023;18:232-239.

Simulation trainings are widely used to identify safety threats and improve processes. By analyzing video recordings of pediatric cardiac arrest simulations, researchers were able to identify 5 main areas of errors: clinical, planning and execution, communication, distraction, and knowledge/training. Investigating the root causes of these errors can result in improved trainings and, thus, improved patient outcomes.

Handling injectable medications in anaesthesia: Guidelines from the Association of Anaesthetists.

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Kinsella SM, Boaden B, El‐Ghazali S, et al. Anaesthesia. 2023;78:1285-1294.

Anesthesia provision is a high-risk practice. This guidance provides practical steps to ensure perioperative medication delivery is as safe as possible. This material recommends approaches for both clinicians and organizations to enable collaborative safety efforts in anesthesia, including prefilled syringes, standardization, and adherence to safe labeling practices.

Sentinel Event Alert 67: Preserving Patient Safety After a Cyberattack.

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Jt Comm J Qual Patient Saf. 2023;49:724-729.

Cyberattacks and technology disruptions are increasing as a threat to patient safety. This alert identifies risks linked to cyberattacks. The authors discuss how organizations might be proactive in order to prevent the potential for data breaches and reduce their impact on care delivery and processes should cyberattacks occur.

A data-driven approach to evaluate barcode-assisted medication preparation alerts at a large academic medical center.

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Joshi RN, Kalaminsky S, Feemster A-A, et al. Jt Comm J Qual Patient Saf. 2023;49:599-603.

Technology, such as barcode scanning, is a recognized method for improving medication safety, but poor design may lead to alert fatigue. This article describes a quality improvement project to reduce barcode-assisted medication preparation alerts in the hospital's pharmacies. More than 40% of alerts were identified as "barcode not recognized," such as packages containing more than one barcode. Problems associated with the highest volume of alerts were resolved with staff education, workflow changes, and changes.

Incivility in healthcare: the impact of poor communication.

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Guppy JH, Widlund H, Munro R, et al. BMJ Lead. 2023;Epub Jul 7.

Incivility hinders clinical performance, increases errors, and negatively impacts safety culture. This review examines recent literature on the effects of incivility in healthcare and strategies to address it. The article proposes ways to implement those strategies, with an emphasis on the UK National Health Service. The authors conclude that tackling incivility begins with highlighting the issue organizationally, regionally, and nationally; ensuring robust reporting and recognition strategies; and, devising mechanisms to confront incivility.

Meta-analysis of medication administration errors in African hospitals.

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Alemu W, Cimiotti JP. J Healthc Qual. 2023;45:233-241.

Medication administration is a complex process and prone to errors. This review was conducted to identify predictors and incidence of medication administration errors (MAE) in African hospitals. Most predictors were at the system level (e.g., work environment, interruptions), followed by patient and professional/provider factors. As the number of included studies was low (13 studies) and most came from one nation, additional studies are needed.

Exploring everyday work as a dynamic non-event and adaptations to manage safety in intraoperative anaesthesia care: an interview study.

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Olin K, Klinga C, Ekstedt M, et al. BMC Health Serv Res. 2023;23:651.

The operating room is a high-risk environment involving complex tasks. This study used cognitive task analysis (CTA) to explore how anesthesia nurses and anesthesiologists manage complex everyday situations during intraoperative care processes. Findings underscore the importance of available resources, team composition, and non-technical skills (NTS) for managing complex daily work and promoting patient safety.

Content analysis of nurses' reflections on medication errors in a regional hospital.

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Issacs AN, RAYMOND A, KENT B. Contemp Nurse. 2023;59:202-213.

Despite widespread improvement efforts, medication administration errors (MAE) remain a patient safety problem. In this study, nurses at one Australian hospital provided a reflection as to why they believed an MAE occurred and these reflections were subsequently analyzed using a human factors framework. Individual characteristics, nature of the work, and physical environment factors were identified as contributing to MAE and represent areas for improvement.

Assessing the impact of a new pediatric healthcare facility on medication administration: a human factors approach.

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Godin MR, Nasr AS. J Nurs Adm. 2023;53:331-336.

Hospital design has been associated with patient safety incidents. This study compared rates of medication administration errors in the pediatric unit of a new evidence-based design (EBD) hospital with rates at the older facility prior to moving to the EBD hospital. Despite implementing EBD, rates of distractions were lower at the older facility; “interruption by physician” was the only distraction type to improve in the new EBD hospital.

Overlapping surgery in arthroplasty - a systematic review and meta-analysis.

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Kim RG, An VVG, Lee SLK, et al. Orthop Traumatol Surg Res. 2023;109:103299.

Overlapping surgery, where “critical” portions of surgery are performed sequentially in separate operating rooms, is used to increase efficiency and number of procedures performed each day. This systematic review and meta-analysis was performed to determine differences in risk of complications between overlapping surgery (OS) and non-overlapping surgery (NOS) in total hip and total knee arthroplasty. Consistent with prior studies and reviews, there were no significant differences in adverse events or complications between OS and NOS. The authors stress that informed consent and patient education prior to OS is critically important.

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.

Distractions in the operating room: a survey of the healthcare team.

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Nasri B-N, Mitchell JD, Jackson C, et al. Surg Endosc. 2023;37:2316-2325.

Distractions in the operating room can contribute to errors. Based on survey responses from 160 healthcare workers, this study examined perceived distractions in the operating room. All participants ranked auditory distractions as the most distracting and visual distractions as the least distracting, but the top five distractors fell into the equipment and environmental categories – (excessive heat/cold, team member unavailability, poor ergonomics, equipment unavailability, and competitive demand for equipment). Phone calls/pagers/beepers were also cited as a common distractor.

Managing interruptions to improve diagnostic decision-making: strategies and recommended research agenda.

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Sloane JF, Donkin C, Newell BR, et al. J Gen Intern Med. 2023;38:1526-1531.

Interruptions during diagnostic decision-making and clinical tasks can adversely impact patient care. This article reviews empirically-tested strategies from healthcare and cognitive psychology that can inform future research on mitigating the effects of interruptions during diagnostic decision-making. The authors highlight strategies to minimize the negative impacts of interruptions and strategies to prevent distractions altogether; in addition, they propose research priorities within the field of diagnostic safety.

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