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 101 - 120 of 18906 Results

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.

“Copy and Paste” Notes and Autopopulated Text in the Electronic Health Records.

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WebM&M Case October 31, 2023

This WebM&M describes two cases illustrating several types of Electronic Health Record (EHR) errors, with a common thread of erroneous use of electronic text-generation functionality, such as copy/paste, copy forward, and automatically pulling information from other electronic sources to populate clinical notes. The commentary discusses other EHR-based documentation tools (such as dot phrases), the influence of new documentation guidelines, and the role of artificial intelligence (AI) tools to capture documentation.

Delay in Malignancy Diagnosis Reflects Systemic Failures.

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WebM&M Case October 31, 2023

A 32-year-old man presented to the hospital with a comminuted midshaft femoral fracture after a bicycle accident. Imaging suggested the fracture was pathologic and an open biopsy specimen was submitted to pathology for intraoperative consultation.

Digital Health Literacy

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Patient Safety Primer October 31, 2023

Many people have trouble understanding health information. As more people search for health information online, it is critical that people are able to obtain accurate health information and access healthcare services.

Hospital Harm Project.

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Canadian Institute for Health Information, Health Excellence Canada.

Reducing preventable harm associated with health care is a worldwide goal. This Canadian initiative developed a measure to track unintended harm in acute care hospitals, a toolkit to accompany reduction efforts, and reports that assess the results of improvement efforts and provide data analysis.

AHRQ Impact Case Studies: Patient Safety.

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Agency for Healthcare Research and Quality. 2019-2023.

AHRQ supports the development and testing of various resources for health care organizations to implement as safety improvement strategies. This collection of case studies highlights AHRQ-funded patient safety tools, including the Comprehensive Unit-based Safety Program, Re-Engineered Discharge Toolkit, and patient safety culture surveys, to document their successful use in the field.

Toxic leadership and its relationship with outcomes on the nursing workforce and patient safety: a systematic review.

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Labrague LJ. Leadersh Health Serv (Bradf Engl). 2023;Epub Oct 9.

Leadership behaviors have an important impact on the workforce and work environment in both positive and negative ways. This review summarizes how toxic leadership impacts the nursing workforce and patient safety. Within the patient safety theme, toxic leadership was significantly associated with increased falls, nosocomial infections, and medication errors.

Second victim syndrome in intensive care unit healthcare workers: a systematic review and meta-analysis on types, prevalence, risk factors, and recovery time.

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Naya K, Aikawa G, Ouchi A, et al. PLoS One. 2023;18:e0292108.

Healthcare workers who are involved in patient safety incidents and experience adverse psychological or emotional outcomes are often referred to as second victims. This systematic review and meta-analysis found that 58% of healthcare workers in intensive care unit (ICU) settings have experienced second victim outcomes, including guilt, anxiety, anger at oneself, and decreased self-confidence. The review also found that one in five individuals took longer than 12 months to recover or did not recover at all, underscoring the importance of organizational support programs for healthcare workers involved in patient safety incidents.

Impact of leadership walkarounds on operational, cultural and clinical outcomes: a systematic review.

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Foster M, MHA BS, Mazur L. BMJ Open Qual. 2023;12:e002284.

Healthcare leadership walkarounds (LWs) involve organizational leaders visiting hospital wards to hear directly from frontline staff about concerns and what is going well. This systematic review describes the impact of LWs on organizational and patient outcomes. Most studies (11 out of 12) measured organizational or clinical outcomes. Organizational outcomes included staff perception of safety culture, near miss reports, teamwork, and feeling heard. Only one study investigated the association between LWs and clinical outcomes; in that study, catheter-associated urinary tract infections decreased following implementation of LW.

Improving patient safety by shifting power from health professionals to patients.

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BMJ 2023(383):2219, 2278, 2319, 2331.

This compendium of editorials and opinion pieces discuss “Martha’s Rule,” a new policy in the United Kingdom motivated by the death of a pediatric patient to sepsis and the systemic weaknesses contributing to the adverse outcome. The policy is intended to encourage patients and caregivers to request a second opinion if a patient’s health condition is deteriorating and they feel their concerns are not being taken seriously by the healthcare team. The articles discuss the importance effective communication between clinicians, caregivers, and patients, mitigating adverse impacts of hierarchies, and the role of patient and caregiver engagement in the design of safe healthcare systems.

Bringing the equity lens to patient safety event reporting.

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Gandhi TK, Schulson LB, Thomas AD. Jt Comm J Qual Patient Saf. 2023;Epub Sept 12.

Safety event reporting from both providers and patients is subject to bias. The authors of this commentary present several ways bias is introduced into reporting and offers strategies to ensure events are reported and analyzed in an equitable manner.

Deficiencies in Facility Leaders' Response to Critical Surgical Events at the Michael E. DeBakey VA Medical Center in Houston, Texas.

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Washington, DC: The Veterans Affairs Inspector General. October 4, 2023. Report No. 23-00080-227.

Wrong-site surgery and unintentionally retained surgical items are considered never events. This report details five wrong-site surgeries and three instances of retained surgical items at one VA medical center between 2018 and 2022. The findings suggest that timely investigation into events from 2018-2021 may have prevented three incidents in 2022. Additionally, the medical center failed to fully report the provider responsible for three of the wrong-site surgeries.

Achieving a successful patient safety program with implementation of a harm reduction strategy.

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Cohen JB. APSF Newsletter. 2023;38(10):93-95.

Zero harm, while a laudable goal, has been shown to have unintended consequences. This commentary calls for a morally neutral approach to human error, an elimination of blame in favor of a just culture, and harm reduction efforts that target the system instead of the individual.

Medication safety events after acute myocardial infarction among veterans treated at VA versus non-VA hospitals.

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Weeda ER, Ward R, Gebregziabher M, et al. Med Care. 2023;Epub Oct 4.

Fragmentation of care between inpatient and outpatient settings can lead to poor patient outcomes. Based on a cohort of veterans ages 65 years or older who had a myocardial infarction, this study examined the use of outpatient medications for secondary prevention (e.g., beta blockers, statins) in the preceding 30 days among patients treated at Veterans Health Administration (VA) versus non-VA hospitals. The researchers found that medication omissions, duplications and delays in prescribing of secondary prevention medications were more common among patients treated at non-VA hospitals.

The effect of evidence in crisis learning: based on a perspective integration framework.

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Wang B, Li D, Wang Y. J Contingencies Crisis Manag. 2023;Epub Oct 4.

Healthcare workers often must deliver care during complex situations. Using insights from safety science and political/social perspectives, the authors outline a new evidence-informed crisis learning framework. They use two sets of crisis event cases to describe how this framework can be used to examine the underlying causes and implications of the crises, which can inform strategies to promote safe patient care in the midst of complex, emergent situations.

Flow of information contributing to medication incidents in home care- an analysis considering incident reporters' perspectives.

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Vellonen M, Härkänen M, Välimäki T. J Clin Nurs. 2023;Epub Oct 6.

Ensuring medication safety in home care settings has unique challenges. In this study, researchers analyzed 1,027 incident reports involving medication errors and communication between home care and inpatient care settings. Four types of issues were identified – (1) information management such as incomplete medication lists or fragmentation of patient data, (2) cooperation between care team members, (3) work environment and lack of resources, and (4) individual-level factors, such as inadequate skills or human error.

Medication safety amid technological change: usability evaluation to inform inpatient nurses' electronic health record system transition.

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Reale C, Ariosto DA, Weinger MB, et al. J Gen Intern Med. 2023;38:982-990.

Barcode mediation administration (BCMA) can reduce medication errors, but workarounds can hinder its effectiveness. Using simulations, this study explored potential medication-related errors associated with BCMA during an electronic health record (EHR) transition. The study was able to identify potential problems with both the old and new systems and provide performance data against which to benchmark future system and/or workflow changes.

Beyond the surgical safety checklist: using intraoperative handoff to facilitate team situation awareness in the OR.

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Ramjaun A, Hammond Mobilio M, Wright N, et al. Ann Surg. 2023;278:e1142-e1147.

Situational awareness is an essential component of teamwork. This qualitative study examined how situational awareness and team culture impact intraoperative handoff practice. Researchers found that participants often assumed that team members are interchangeable and that trained staff should be able to determine handoff appropriateness without having to consult the larger operating room team – both of these assumptions hinder team communication and situational awareness.

Observing sources of system resilience using in situ alarm simulations.

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McLoone M, McNamara M, Jennings MA, et al. J Hosp Med. 2023;18:994-998.

Healthcare workers can become desensitized to electronic safety alerts (alert fatigue) which can lead to errors and adverse events. Based on Safety II concepts such as organizational resilience and using in situ simulations of critical hypoxemic-event alarms in pediatric inpatient settings, this study identified four types of system resilience contributing to alarm resilience – secondary notification, team-based care, direct visualization of bedside monitors from outside patient rooms (or a central monitoring station) and presence at the bedside.

Safety of office-based lens surgery: U.S. multicenter study

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Kugler LJ, Kapeles MJ, Durrie DS. J Cataract Refract Surg. 2023;49:907-911.

Cataract surgery is a common ophthalmic procedure in the United States and is increasingly performed in office-based settings. This study assessed the rates of intra- or post-operative adverse events in three types of lens surgeries, including cataracts. Findings suggest similar or lower adverse event rates for office-based cataract or refractive lens surgery when compared to surgeries performed in ambulatory surgery centers or hospital operating rooms.

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