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 81 - 100 of 18731 Results

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 Safety Executive Development Program.

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Institute for Healthcare Improvement. Boston, MA and online. August 30-October 13, 2023.

Organization executives influence the success of patient safety improvement. This hybrid workshop will highlight how leaders can use assessments, planning, and evidence to improve the safety culture at their organizations.

Sleep Deprivation Leads to Medication Error During Spinal Epidural Anesthesia.

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WebM&M Case August 30, 2023

This case describes a 27-year-old primigravid woman who requested neuraxial anesthesia during induction of labor. The anesthesia care provider, who was sleep deprived near the end of a 48-hour call shift (during which they only slept for 3 hours), performed the procedure successfully but injected an analgesic drug that was not appropriate for this indication. As a result, the patient suffered slower onset of analgesia and significant pruritis, and required more prolonged monitoring, than if she had received the correct medication.

Personal Health Literacy

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Patient Safety Primer August 30, 2023

Anyone can find it challenging to understand medical terms, and millions of Americans have trouble understanding and acting upon health information. The mismatch between individuals' health literacy skills and the complexity of health information and health care tasks involved in managing health has implications on patient safety.

National Action Alliance to Advance Patient Safety Webinar Series.

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US Department of Health and Human Services. September 26, 2023. 2:00-3:00 PM (eastern).

Work toward zero harm in health care is gaining national attention in the United States. This webinar aligns with efforts by the National Action Alliance to Advance Patient Safety. The session will explore the successful application of high reliability concepts at the Veterans Health Administration. This is the fifth in a series of offerings from the Alliance supporting its work to improve safety.

Exploring medication safety structures and processes in nursing homes: a cross-sectional study.

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Favez L, Zúñiga F, Meyer-Massetti C. Int J Clin Pharm. 2023;Epub Aug 10.

Effective implementation of health information technology can promote medication safety. This survey of 118 nursing homes in Switzerland found that organizations employ a variety of electronic health record (EHR)-based tools to support medication safety, such as standardized medication lists, alerts for potentially inappropriate prescribing, or electronic data exchanges with community pharmacies or outside physicians.

A natural language processing approach to categorise contributing factors from patient safety event reports.

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Tabaie A, Sengupta S, Pruitt ZM, et al. BMJ Health Care Inform. 2023;30(1):e100731.

Analyzing patient safety incident reports is essential to organizational learning, but comes with both a time and financial burden. This study found that natural language processing can be used to process unstructured patient safety event reports and reduce the burden of manually identifying and extracting factors contributing to the event.

Opportunities to improve diagnosis in emergency transfers to the pediatric intensive care unit.

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Mehta SD, Congdon M, Phillips CA, et al. J Hosp Med. 2023;18:509-518.

Improving diagnosis in pediatrics is an ongoing patient safety focus. This retrospective study included 129 pediatric emergency transfer cases and examined the relationship between missed opportunity for improvement in diagnosis (MOID; determined using SaferDx) and patient outcomes. Researchers found that MOID occurred in 29% of emergency transfer cases and it was associated with higher risk of mortality and longer post-transfer length of stay.

Striving for diagnostic excellence.

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Centor RM, Dhaliwal G. Annals On Call. July 2023.

Diagnostic accuracy requires both cognitive and team-focused skill development. This podcast interview shares problem-solving tactics that support diagnostic excellence and how to measure it. Tracking diagnosis outcomes at a patient level is one strategy discussed.

Drug shortages.

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Aronson JK, Heneghan C, Ferner RE. Br J Clin Pharmacol. Epub 2023 Jul 16.

Addressing drug shortages is a patient safety priority. Part One of this review summarizes existing definitions for drug shortages and the harms that can occur due to drug shortages (e.g., medication errors, treatment delays, undertreatment). Part Two discusses trends in drug shortages, the causes of drug shortages, and potential solutions.

Barriers and facilitators to implementing interventions for reducing avoidable hospital readmission: systematic review of qualitative studies.

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Fu BQ, Zhong CCW, Wong CHL, et al. Int J Health Policy Manag. 2023;12:7089.

Peri-discharge interventions aim to reduce potential adverse events that can arise during and after hospital discharge. This systematic review of 13 qualitative studies identified common barriers and facilitators to implementing peri-discharge interventions. Frequently cited barriers included limited resources, poor team communication, and complicated intervention processes; common facilitators included leadership support, a positive organizational culture, and financial penalties.

Hospital bosses ignored months of doctors' warnings about Lucy Letby.

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Moritz J, Coffey J, Buchanan M. BBC News. August 19, 2023.

Whistleblowers can identify the presence of systemic failures, but the organization is responsible for acting on their reported concerns. This article summarizes the range of breakdowns that contributed to a British nurse serial murderer, who, despite warnings from others, continued to harm babies over several years.

Quality and safety practices among academic obstetrics and gynecology departments.

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Christopher D, Leininger WM, Beaty L, et al. Am J Med Qual. 2023;38:165-173.

Staff engagement in safety and quality improvement efforts fosters a culture of safety and can reduce medical errors. This survey of 52 obstetrics and gynecology departments at academic medical centers found that few departments provided faculty with protected time or financial support for quality improvement activities, and only 5% of departments included a patient representative on the quality committee.

Activating pharmacists to reduce the frequency of medication-related problems (ACTMed): a stepped wedge cluster randomised trial.

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Spinks J, Violette R, Boyle DIR, et al. Med J Aust. 2023;Epub Aug 16.

Medication safety in ambulatory care settings is an area of growing concern. This article describes ACTMed (ACTivating primary care for MEDicine safety), a cluster randomized trial set in Australia which intends to improve medication safety in primary care settings. The ACTMed intervention will use health information technology (e.g., clinical indicator algorithms), guideline-based clinical recommendations, shared decision-making, and financial incentives to reduce serious medication-related harm, medication-related hospitalizations, and death.

Exploring the impact of safety culture on incident reporting: lessons learned from machine learning analysis of NHS England staff survey and incident data.

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Kaya GK, Ustebay S, Nixon J, et al. Safety Sci. 2023;166:106260.

Voluntary incident reporting rates may be an indicator of organizational safety culture. Using different machine learning algorithms, this study found that several components of safety culture – compassionate culture, violence and harassment, and work pressure – have a significant impact on predicting incident reporting behavior.

Virtual Research Meeting on Patient Experience, Patient Safety, and Provider Well-Being: Associations and Paths for Quality Improvement.

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CAHPS Research Meetings. Agency for Healthcare Research and Quality, Rockville, MD. October 19, 2023; 11:00 AM—4:00 PM (eastern).

Patient narrative is an important resource for understanding care delivery. This webinar will discuss how Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys can provide patient experience insights that could inform safety culture improvement efforts and lower risks stemming from poor patient/team communication.

Effect of lawsuits on professional well-being and medical error rates among orthopaedic surgeons.

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Adelani MA, Hong Z, Miller AN. J Am Acad Orthop Surg. 2023;31:893-900.

Previous analyses have found that orthopedic surgery is one common source of patient harm. This survey of 305 orthopedists found that involvement in a medical malpractice lawsuit within the past two years increased the likelihood of experiencing burnout and reporting a medical error resulting in patient harm in the past year.

Healthcare fragmentation, multimorbidity, potentially inappropriate medication, and mortality: a Danish nationwide cohort study.

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Prior A, Vestergaard CH, Vedsted P, et al. BMC Med. 2023;21:305.

System weaknesses (e.g., resource availability, deficiencies in care coordination) threaten patient safety. This population-based cohort study including 4.7 million Danish adults who interacted with primary or hospital care in 2018, found that indicators of care fragmentation (e.g., higher numbers of involved clinicians, more transitions between providers) increased with patient morbidity level. The researchers found that higher levels of care fragmentation were associated with adverse outcomes, including potentially inappropriate prescribing and mortality.

2022 John M. Eisenberg Patient Safety and Quality Awards.

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Jt Comm J Qual Patient Saf. 2023;49(9):435-450.

The legacy of AHRQ leader John Eisenberg, MD, still inspires safety improvement work decades after his passing. This special issue highlights the efforts of the 2022 Eisenberg Award honorees and their impact on improving patient safety and quality. The 2022 award recipients coved here include Jason S. Adelman, MD, MS, and North American Partners in Anesthesia (NAPA).

The Pursuing Excellence Collaborative: engaging first-year residents and fellows in patient safety event investigations.

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Paull DE, Newton RC, Tess AV, et al. J Patient Saf. 2023;19:484-492.

Previous research suggests that residents may underutilize adverse event reporting tools. This article describes an 18-month clinical learning collaborative among 16 sites intended to increase resident and fellow participation in patient safety event investigations. Researchers found the collaborative increased participation in event investigation and improved the quality of the investigation.

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