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 4246 Results

Advancing Diagnostic Excellence for Maternal Health Care: Proceedings of a Workshop–in Brief.

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National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2023. ISBN: 9780309711937.

Maternal health care is rapidly emerging as a high-risk service that is vulnerable to communication, equity, and diagnostic challenges. This report examines the role of disparities in care across the maternal care continuum and strategies to drive diagnostic improvement such as care bundles, midwives, and health information technology. This publication is from a series of programs and resultant publications on improving diagnostic excellence.

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.

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.

Facilitators and barriers to the implementation of surgical safety checklist (SSC): an integrative review.

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Lim PJH, Chen L, Siow S, et al. Int J Qual Health Care. 2023;35:mzad086.

Surgical safety checklists (SCC) are utilized around the world, but checklist completion at the operating room level remains inconsistent. This review summarizes facilitators and barriers to completion. Resistance or endorsement at the individual surgeon level remains a significant factor in SSC completion. Early inclusion of frontline staff in evaluation and implementation supported increased use.

Use of the Second Victim Experience and Support Tool (SVEST) to assess the impact of a departmental peer support program on anesthesia professionals' second victim experiences (SVEs) and perceptions of support two years after implementation.

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Pelikan M, Finney RE, Jacob A. AANA J. 2023;91(5):371-379.

Providers involved in patient safety incidents can experience adverse psychological and physiological outcomes, also referred to as second victim experiences (SVE). This study used the Second Victim Experience and Support Tool (SVEST) to evaluate the impact of a peer support program on anesthesia providers’ SVE. Two years after program implementation, reported psychological distress decreased and over 80% of participants expressed favorable views of the program and its impact on safety culture.

Identifying barriers and enablers for a robust independent second check of medication in adult intensive care.

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Milic V, Cameron L, Jones C. Br J Nurs. 2023;32:840-848.

Double checking of medication administration one strategy meant to reduce medication errors. In this study, 29 critical care nurses took part in a focus group exploring the barriers to double-checking during medication administration. Participants discussed several challenges, such as patient location (particularly for patients in isolation due to infection control measure), health IT limitations, and unclear roles and responsibilities.

Preferred language and diagnostic errors in the pediatric emergency department.

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Lowe JT, Leonard J, Dominguez F, et al. Diagnosis (Berl). 2023;Epub Oct 6.

Non-English primary language (NEPL) patients may encounter barriers navigating the healthcare system and communicating with providers. In this retrospective study, researchers used the Safer Dx tool to explore differences in diagnostic errors among NEPL versus English-proficient (EP) patients. Among 172 patients who experienced a diagnostic error, the proportion was similar among EP and NEPL groups and NEPL did not predict higher odds of diagnostic error.

Using in situ simulation to identify latent safety threats in emergency medicine: a systematic review.

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Grace MA, O'Malley R. Simul Healthc. . 2023;Epub Sep 19.

In situ simulation can reveal latent safety threats before they cause harm. This review identified 15 studies of in situ simulations conducted in the emergency department including simulations conducted prior to opening new facilities and to address emerging COVID-19 concerns. The most commonly identified safety threats were related to equipment and team communication.

Handoff tool improves transitions from the operating room to the neonatal intensive care unit.

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Gallois JB, Zagory JA, Barkemeyer B, et al. Pediatr Qual Saf. 2023;8:e695.

Structured handoff tools can improve situational awareness and patient safety. This study describes the development and implementation of a bespoke tool for handoffs from the operating room to the neonatal intensive care unit (NICU). While use remained inconsistent during the study period, the goal of 80% compliance was achieved and 83% surveyed staff agreed or strongly agreed that the handoff provided needed information, up from 21% before implementation.

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.

Impact of hospital-acquired pneumonia on the Medicare program.

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Baker DL, Giuliano KK, Desmarais M, et al. Infect Control Hosp Epidemiol. 2023;Epub Oct 25.

Hospital-acquired pneumonia (HAP) is one of the most common healthcare-associated infections in the United States. In this case-control retrospective study of Medicare beneficiaries, patients with HAP were 2.8 times more likely to die than patients without HAP. Length of stay and overall cost were also significantly higher in the HAP group. The authors suggest quality improvement efforts like the Keystone ICU project could decrease HAP rates, saving lives and money.

Sentinel Event Alert 68: Updated surgical fire prevention for the 21st Century.

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Jt Comm J Qual Patient Saf. 2023;Epub Oct 18.

Surgical fires are a rare yet potentially harmful event for both patients and care teams. The alert provides reduction guidance for organizations to mitigate conditions that enable surgical fires and suggests tactics to improve communication as a primary strategy for preventing this potentially catastrophic accident in operating rooms.

Adverse drug event prevention and detection in older emergency department patients.

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Koehl JL. Clin Geriatr Med. 2023;39:635-645.

Older adults are at increased risk of medication errors due to medical complexity and polypharmacy. This article discusses medication safety and adverse drug events specific to a geriatric population and highlights prescribing and deprescribing tools that can contribute to safer prescribing practices.

Perioperative Safety Culture: Principles, Practices, and Pragmatic Approaches.

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McEvoy MD, Abernathy JH, 3rd. Anesthesiol Clin. 2023;41(4):xvii-xix;693-886.

Organizational, unit, and team culture affect the safety of surgical care. This special issue examines overarching principles, common practices, and practical actions that support safe perioperative processes and settings. Topics discussed include team dynamics, operating room design, and high reliability.

Building cultures of high reliability: lessons from the high reliability organization paradigm.

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Sutcliffe KM. Anesthesiol Clin. 2023;41:707-717.

Achieving high reliability remains difficult for many organizations. This article provides a brief history of the concept of high reliability organizations (HROs) and key features of high reliability culture, such as fostering trust and respect among teams and creating systems and processes to elicit feedback/reflections and identify opportunities for improvement. The authors discuss these concepts in the setting of anesthesiology and perioperative care.

Failure to rescue as a patient safety indicator for neurosurgical patients: are we there yet?

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Roy JM, Rumalla K, Skandalakis GP, et al. Neurosurg Rev. 2023;46:227.

Failure to rescue (FTR) quality metrics measure the ability of healthcare teams and hospitals to prevent mortality following a major complication. This systematic review included 12 studies and examined how FTR has been used in neurosurgical populations. The authors discuss several modifications to existing FTR definitions to better suit neurosurgical patients, such as incorporating measures of baseline frailty.

Use of design thinking and human factors approach to improve situation awareness in the pediatric intensive care unit.

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Gifford A, Butcher B, Chima RS, et al. J Hosp Med. 2023;Epub Oct 4.

Shared situation awareness is shown to improve patient outcomes in the pediatric intensive care unit (PICU). This article outlines the process of designing communication and signage tools to maintain or improve situational awareness in anticipation of moving to a new clinical space. With the new tools in place in the new PICU, shared situation awareness for residents, nurses, and respiratory therapists improved.

Addressing Workplace Violence and Creating a Safer Workplace

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Perspective on Safety October 31, 2023

This piece focuses on workplace violence trends in healthcare settings and strategies for creating a safer healthcare environment.

In Conversation with Cheryl Jones about Addressing Workplace Violence and Creating a Safer Workplace

Editor’s note: Cheryl B. Jones is a professor, director of the Hillman Scholars Program, and interim associate dean of the School of Nursing’s PhD program at the University of North Carolina at Chapel Hill. We spoke to her about workplace violence trends in healthcare settings and how we can create a safer work environment for healthcare staff.

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.

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