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 181 - 200 of 18757 Results

Quality and Safety in Health Care.

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Harolds JA, Harolds LB. Clin Nucl Med. 2015–2023.

This monthly commentary explores a wide range of subjects associated with patient safety, such as infection prevention, six sigma, and high reliability organizations.

Annual Communication, Apology, and Resolution (CARe) Forum.

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Betsy Lehman Center for Patient Safety. September 29, 2023, 10:00 AM - 12:30 PM (eastern).

Communication and resolution programs are a promising strategy for successful management of relationships and actions after medical error occurrence. This annual hybrid session explores elements of effective discussions after an adverse event through case simulation and dialogue. The site also includes an archive of videos and materials from previous forums.

Final Report on Prioritization of Patient Safety Practices for a New Rapid Review or Rapid Response. Making Healthcare Safer IV Series.

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Rosen M, Dy SM, Stewart CM, et al. Making Healthcare Safer IV Series. Rockville, MD: Agency for Healthcare Research and Quality; July 2023. AHRQ Publication no. 23-EHC019-1.

Reducing preventable harm in healthcare settings remains a national priority. This report summarizes the results of the prioritization process used to identify patient safety practices meriting inclusion in the fourth installment of the Making Healthcare Safer (MHS) series (previous installments were published in 2001, 2013, and 2020). The fifteen-member Technical Expert Panel identified 27 priority patient safety practices for examination in the forthcoming report, including several practices that have not been covered in previous MHS reports (e.g., family/caregiver engagement, preventing non-ventilator associated pneumonia, supply chain disruption, high reliability, post-event communication programs).

Implementation of barcode medication administration (BMCA) technology on infusion pumps in the operating rooms.

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Hogerwaard M, Stolk M, Dijk L van, et al. BMJ Open Qual. 2023;12:e002023.

Barcode medication administration (BCMA) technology is a useful tool to reduce medication administration errors (MAE) in the operating room. This study used a pre-post design to estimate the rate of MAE before and after BCMA implementation on infusion pumps. MAE were significantly reduced and up to 90% of errors were considered preventable, if the staff had utilized BCMA. Reasons for not using BCMA included unreadable barcodes, lack of time, and resistance to new processes.

Accuracy of infection reporting in US nursing home ratings.

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Chen Z, Gleason LJ, Konetzka RT, et al. Health Serv Res. 2023;58:1109-1118.

Researchers and patient advocates have raised concerns about the accuracy of self-reported data on Care Compare, the Medicare and Medicaid website that publicly reports facility-level quality and safety measures of certified facilities, including nursing homes. This study used hospital claims to determine the percentage of nursing home residents admitted to a hospital for a urinary tract infection (UTI) and compared that number to rates reported on Care Compare. The results show only 79% of claims-based UTIs were reported by the facility. Reporting rates for Black residents or nursing homes with a higher percentage of Black residents were even lower.

Parent experiences with the process of sharing inpatient safety concerns for children with medical complexity: a qualitative analysis.

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Kieren MQ, Kelly MM, Garcia MA, et al. Acad Pediatr. 2023;Epub Jun 9.

Parents of children with medical complexity are an important part of the care team and can raise awareness of safety concerns. This study included parents of children with medical complexity who had reported safety concerns to members of their child's healthcare team. Parents whose concerns were validated and addressed felt increased trust in the team and hospital, whereas those whose concerns were invalidated or ignored felt disrespected and judged.

‘Medical errors are the third leading cause of death’ and other statistics you should question.

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Jaklevic MC. HealthJournalism.org. July 27, 2023.

Published rates of medical errors continue to draw attention to gaps in care that demonstrate the need for continued effort toward development and implementation of system-focused safety solutions. This article discusses the importance of representing error statistics responsibly and offers recommendations to ensure accurate representations of the challenges facing safe care delivery.

Redesign of health care systems to reduce diagnostic errors: leveraging human experience and artificial intelligence.

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Abid MH. J Clin Outcomes Manag. 2023;30:67-70.

Despite extensive research and education, diagnostic errors continue to be a global health concern. This article encourages a comprehensive strategy combining human (patient) experience and artificial intelligence (AI) to create a safer, more patient-focused health system, specifically concerning diagnostic safety. Key to this strategy is open communication between patients and providers, patient involvement in AI development, and reduction of bias in AI systems.

Why stigma matters in addressing alcohol harm.

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Morris J, Schomerus G. Drug Alcohol Rev. 2023;42:1264-1268.

Stigma and bias in healthcare undermine patient safety. This article discusses how stigma associated with alcohol use can impede the delivery of quality health care and contribute to poor patient outcomes.

Electronic health record usability contributions to patient safety and clinician burnout: a path forward.

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Schwappach DLB, Ratwani RM. J Patient Saf. 2023;19:38-39.

Usability concerns continue to affect the safe use of electronic health information systems. This commentary describes the role of vendors in improving usability, how regular testing can ensure safety, and the impact of organizational culture on the safe use of information technology over time.

Associations between self-reported healthcare disruption due to COVID-19 and avoidable hospital admission: evidence from seven linked longitudinal studies for England.

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Green MA, McKee M, Hamilton OKL, et al. BMJ. 2023;328:e075133.

Many patients were unable to access care during the pandemic, particularly during surges. This longitudinal cohort study in the UK reports that 35% of participants reported disrupted access to care (e.g., cancelled or postponed appointments or procedures). While overall rates of potentially preventable hospitalization were low (3%), those who reported disrupted access had increased risk of potentially preventable hospitalization.

Implementation of medication reconciliation in outpatient cancer care.

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Powis M, Dara C, Macedo A, et al. BMJ Open Quality. 2023;12:e002211.

Medication reconciliation can help providers identify potential safety issues during medication administration. Based on interviews with stakeholders, this study examined medication reconciliation practices across Canadian cancer centers. Although a high proportion of the centers had a process for collecting best possible medication history (BPMH, 81%), implementation of a complete medication reconciliation process was uncommon. Stakeholders identified several barriers to implementation, including lack of resources and a lack of electronic health record interoperability across institutions, systems, and community pharmacies.

Physician burnout and medical errors: exploring the relationship, cost, and solutions received.

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Li CJ, Shah YB, Harness ED, et al. Am J Med Qual. 2023;38:196-202.

Burnout among healthcare workers is a public health concern. This systematic review explores the link between physician burnout and medical errors, the influence of physician demographics (e.g., specialty, level of training) and the financial impact of physician burnout.

Risk Evaluation and Mitigation Strategy (REMS) Programs and Medication Safety: Parts I and II.

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ISMP Medication Safety Alert! Acute care edition. July 13, 2023;(4):1-3;July 27, 2023;(5):1-5.

Risk Evaluation and Mitigation Strategy (REMS) programs help to ensure the safe use of distinct medications through communication, patient information, and implementation support. Part I of this article series examines systemic barriers to the deployment of REMS as a strategy to decrease potential for drug-related harm and medication error. Part II looks at the processes that one health system used to implement REMS.

Assessment of a wearable fall prevention system at a Veterans Health Administration hospital.

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Osborne TF, Veigulis ZP, Arreola DM, et al. Digit Health. 2023;9:20552076231187727.

Preventing patient falls in hospital settings is a patient safety priority. Set at one Veterans Health Administration (VHA) hospital, this study found that use of SmartSocks – socks containing pressure sensors that detect when a patient is trying to stand up – reduced falls by more than 50% among patients determined to be at high-risk of falling.

Improving emergency medicine clinician awareness of prehospital-administered medications.

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Kamta J, Fregoso B, Lee A, et al. Prehosp Emerg Care. 2023;Epub Jul 28.

Handoffs from emergency medical services (EMS) to the emergency department (ED) are vulnerable to communication errors due to the time-pressured environment. This study reports on the implementation of an electronic health record (EHR) tool that added pre-hospital medication administration to the ED triage note to reduce medication administration errors (MAE). Although most ED providers reported they "always" review the triage note, MAE rates did not improve following implementation.

Physician engagement in organisational patient safety through the implementation of a Medical Safety Huddle initiative: a qualitative study.

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Rotteau L, Othman D, Dunbar-Yaffe R, et al. BMJ Qual Saf. 2023;Epub Jul 19.

Safety huddles are increasingly used to encourage team communication about safety threats and learning from mistakes. This qualitative study with huddle leaders and participants at five sites found that huddles can enhance engagement in patient safety and identify opportunities for increased support from organizational leadership.

Identifying failure modes in telemedicine: an instructional needs assessment.

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Monkman H, Kuziemsky C, Homco J, et al. Stud Health Technol Inform. 2023;304:39-43.

Implementation challenges can hinder the safety of telehealth. In this study, medical students used Healthcare Failure Modes and Effect Analysis to identify the causes of failures in telehealth and potential prevention strategies. Four categories of failures were identified: technical issues, patient safety, communication, and social and structural determinants.

Guidelines on Human Factors in Critical Situations 2023.

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Bijok B, Jaulin F, Picard J, et al. Anaesth Crit Care Pain Med. 2023;42:101262.

Human factors influence how humans and systems interact to make processes more reliable or more error-prone during both normal and unexpected circumstances. This guideline provides recommendations centered on elements of communication, the organization, the work environment, and training to guide the consideration of human factors in improvement actions during critical anesthesia or intensive care situations.

Experimental evidence for structured information-sharing networks reducing medical errors.

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Centola D, Becker J, Zhang J, et al. Proc Natl Acad Sci U S A. 2023;120:e2108290120.

Collective intelligence posits that the judgment (in this case, diagnostic accuracy) of a group of individuals outperforms the judgment of a single individual. This study sought to determine if real-time information-sharing improved not only group diagnostic accuracy, but also diagnostic accuracy of the individuals within the group. Individual accuracy did improve, suggesting real-time information-sharing between physicians could improve diagnostic decision-making in practice, although additional research is required.

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