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 73 Results

Coronavirus Disease 2019 (COVID-19) and Diagnostic Error

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Patient Safety Primer January 11, 2022

Diagnostic error has been increasingly recognized as an important and evolving patient safety issue. This Primer applies well-established principles of diagnostic error and improvement of diagnostic accuracy to the topic of COVID-19.

Mix-ups between the influenza (Flu) vaccine and COVID-19 vaccines.

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ISMP Medication Safety Alert! Acute care edition. October 7, 2021;26(20):1-4.

Production pressure and low staff coverage can result in medication mistakes in community pharmacies. This article shares errors reported to the ISMP Vaccine Errors Reporting Program and factors contributing to mistaken administration of flu and COVID vaccines. Storage, staffing and collaboration strategies are shared to protect against vaccine mistakes.

Patient-safety incidents during COVID-19 health crisis in France: An exploratory sequential multi-method study in primary care.

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Fournier JP, Amélineau JB, Hild S, et al. Eur J Gen Pract. 2021;27(1):142-151.

The COVID-19 pandemic has raised new patient safety concerns. This study examined patient safety incidents in primary care settings in France during the early months of the COVID-19 pandemic. Of the 132 reported incidents, 44% related to delayed diagnosis, assessments and referrals. Reported incidents less commonly related to cancellation of care, home confinement-related incidents, and inappropriate medication discontinuation.

Critical care nurses’ physical and mental health, worksite wellness support, and medical errors.

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Melnyk BM, Tan A, Hsieh AP, et al. Am J Crit Care. 2021;30:176-184.

This survey of 771 critical care nurses found that 40% had at least one symptom of depression and nearly half experienced some degree of anxiety. Nurses with poor physical or mental health reported making more medical errors than their healthier counterparts and nurses in supportive workplaces were more likely to have better physical and mental health. The authors suggest that improvements in an organization’s health and wellness support programs could result in fewer reported medical errors. Notably, this study was completed prior to the COVID-19 pandemic which has led to an even further decline in nurse wellness.

COVID-19 and open notes: a new method to enhance patient safety and trust.

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Blease CR, Salmi L, Hägglund M, et al. JMIR Ment Health. 2021;8:e29314.

This commentary outlines six benefits of the new requirement that health systems offer online patient access to their medical records, including clinician notes. Benefits include strengthened patient-clinician relationships, patient engagement, and adherence to mental health care plans. While online access may help narrow the digital divide, the authors also point out that lack of access to technology is still a barrier.

How medical jargon can make COVID health disparities even worse.

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Kritz F. Health Shots. National Public Radio; May 24, 2021.

Health literacy efforts address challenges related to both language and effective communication tactics. This story discussed how lack of language and information clarity reduced patient education effectiveness during the pandemic and highlights several efforts to address them including information product translation services.

Redeployment of health care workers in the COVID-19 pandemic: a qualitative study of health system leaders' strategies.

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Panda N, Sinyard RD, Henrich N, et al. J Patient Saf. 2021;17:256-263.

The COVID-19 pandemic has presented numerous challenges for the healthcare workforce, including redeploying personnel to different locations or retraining personnel for different tasks. Researchers interviewed hospital leaders from health systems in the United States, United Kingdom, New Zealand, Singapore and South Korea about redeployment of health care workers during the COVID-19 pandemic. The authors discuss effective practices and lessons learned preparing for and executing workforce redeployment, as well as concerns regarding redeployed personnel

Universal protection: operationalizing infection prevention guidance in the COVID-19 era.

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Sands K, Blanchard J, Grubbs K, et al. Jt Comm J Qual Patient Saf. 2021;47:327-332.

This article describes the development of the Universal Protection Framework, which builds upon traditional infection prevention practices and consists of four domains (infection prevention, access control, distancing, and patient flow) supported by communication and education. The framework was implemented in one large health system with high levels of compliance, particularly for handling of personal protective equipment (PPE), cohorting of COVID-19 patients, facility access controls and employee exposure monitoring.

Pandemic imperiled non-English speakers more than others.

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Bebinger M. WBUR and Kaiser Health News. April 27, 2021.

Non-English-speaking patients experience barriers to safely navigating the American healthcare system. This story discusses the impact that language and disparities had on care during the pandemic at one health system, and shares outreach communication and translation strategies to improve care safety.

Has the COVID pandemic strengthened or weakened health care teams? A field guide to healthy workforce best practices.

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Thompson R, Kusy M. Nurs Adm Q. 2021;45:135-141.

Effective leadership is essential to team performance and organizational safety. This article discusses the role of team leaders on team performance during the COVID-19 pandemic. The authors review common mistakes made during the pandemic (such as broken trust or ignoring disruptive behaviors) and lessons learned to help build strong, cohesive teams.

Leadership through crisis: fighting the fatigue pandemic in healthcare during COVID-19.

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Whelehan DF, Algeo N, Brown DA. BMJ Leader. 2021;5:108-112.

Healthcare workers are facing occupational fatigue stemming from the COVID-19 pandemic (e.g., burnout, stress) as well as fatigue related to ongoing symptoms of the virus (“long COVID”). This article discusses preventive and proactive leadership strategies to address both types of fatigue, including screening for fatigue, providing reasonable accommodations for healthcare workers struggling with fatigue, stress mediation, and establishing organizational culture supporting sleep and rest.

AHRQ PSNet Annual Perspective: Impact of the COVID-19 Pandemic on Patient Safety

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Perspective on Safety March 30, 2021

In this PSNet Annual Perspective, we worked with co-authors Dr. Jacqueline C. Stocking, a quality improvement and critical care specialist, and Dr. Christian Sandrock, a patient safety professional and emerging infectious diseases specialist, to provide a look at news and research related to the impact of the COVID-19 pandemic on patient safety.

5 pandemic mistakes we keep repeating. We can learn from our failures.

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Zeynep Tufekci. The Atlantic. February 26, 2021

Failures in communication have impacts on patients, teams, organizations and society. This article discusses five weaknesses in pandemic messaging that were counterproductive including use of shaming instead of empathy to engage the public, lack of detail on suggested strategies and insufficient advice to support public adoption of harm reduction activities.

Keeping patients on track with preventative care during pandemic.

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Quick Safety. March 2021;58:1-2.

The potential exposure to COVID-19 continues to negatively influence patient care seeking activity. This article recommends several strategies for gaining patient trust in the system to keep them safe from exposure which include dedicated spaces for preventative services and proactive encouragement on the importance of screenings such as mammograms.

Approach to Improving Patient Safety: Communication

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Perspective on Safety March 10, 2021

In this PSNet Annual Perspective, we review key findings related to improvement strategies when communicating with patients and different structured communication techniques to improve communication across providers. Lessons learned from innovative approaches explored under COVID-19 that could be considered as usual care resumes are also discussed.

Communication and Transparency as a Means to Strengthening Workplace Culture During COVID-19.

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Nadkarni A, Levy-Carrick NC, Kroll DS, et al. National Academy of Medicine; 2021.

Communication within teams is central to safe care delivery, crisis management, and staff well-being. This report shares the experience of one hospital that used technology to enhance information-sharing as a strategy to reduce clinician burnout in times of uncertainty and crisis.

Avoiding a Med-Wreck: a structured medication reconciliation framework and standardized auditing tool utilized to optimize patient safety and reallocate hospital resources.

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Elbeddini A, Almasalkhi S, Prabaharan T, et al. J Pharm Policy Pract. 2021;14:10.

Medication reconciliation can improve patient safety, but prior research has documented challenges with implementation. Researchers conducted a gap analysis to inform the development of standardized medication reconciliation framework for use across multiple healthcare settings to reduce harm, including during the COVID-19 pandemic. Five key components were identified: (1) pharmacy-led medication reconciliation team, (2) patient education and involvement, (3) complete and accurate medication history, (4) admission and discharge reconciliation, and (5) interprofessional communication.

The I-READI quality and safety framework: a health system’s response to airway complications in mechanically ventilated patients with Covid-19.

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Ginestra JC, Atkins JH, Mikkelsen ME, et al. NEJM Catalyst. 2020;2.

Health systems are rapidly adjusting and adapting processes to successfully respond to the COVID-19 pandemic. The University of Pennsylvania Health System developed the I-READI (integration, root cause analysis, evidence review, adaptation, dissemination, and implementation) conceptual framework to assist hospitals in preparing for and responding to patient safety challenges during times of crisis, such as the COVID-19 pandemic. The I-READI approach can streamline communication, enrich collaboration, and coordinate rapid change through the use of daily safety huddles, root cause analysis, and technology (e.g., ICU telemedicine and real-time ICU dashboards).

TeamSTEPPS for the COVID-19 Crisis.

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AHA Team Training.

The COVID-19 crisis requires cooperation and coordination of organizations and providers to address the persistent challenges presented by the pandemic. This on-demand video collection reinforces core TeamSTEPPS; methods that enhance clinician teamwork and communication skills to manage care safety during times of crisis.

How satisfied are patients and surgeons with telemedicine in orthopaedic care during the COVID-19 pandemic? A systematic review and meta-analysis.

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Chaudhry H, Nadeem S, Mundi R. Clin Orthop Relat Res. 2021;479:47-56.

The COVID-19 pandemic has dramatically increased the use of telehealth across various medical specialties.This systematic review did not identify any differences in patient or surgeon satisfaction or patient-reported outcomes with telehealth for orthopedic care delivery as compared to in-person visits.However, the authors note that the included studies did not adequately capture or report safety endpoints, such as complications or missed diagnoses.

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