Skip to main content

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.

Search All Content

Search Tips
Save
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Search By Author(s)
Additional Filters
Displaying 1 - 20 of 51 Results
Ang D, Nieto K, Sutherland M, et al. Am Surg. 2022;88:587-596.
Patient safety indicators (PSI) are measures that focus on quality of care and potentially preventable adverse events. This study estimated odds of preventable mortality of older adults with traumatic injuries and identified the PSIs that are associated with the highest level of preventable mortality.  Strategies to reduce preventable mortality in older adults are presented (e.g. utilization of national guidelines, minimization of central venous catheter use, addressing polypharmacy).
Walshe N, Ryng S, Drennan J, et al. Int J Nurs Stud. 2021;124:104086.
Situation awareness refers to the degree to which perception matches reality. This narrative review explored how situation awareness has been defined and studied in healthcare, with a particular focus on nursing. Three overarching themes were identified: (1) individual, team and systems perspectives of situation awareness; (2) situation awareness and patient safety, and (3) communication tools, technologies and education to support situation awareness. The authors note that future research should reflect nurse’s work and the constrictions imposed on situation awareness by the demands of busy impatient wards.
McHale S, Marufu TC, Manning JC, et al. Nurs Crit Care. 2023;28:72-79.
Failure to identify and prevent clinical deterioration can reflect the quality and effectiveness of care. This study used routinely collected emergency event data to identify failure to rescue events at one tertiary children’s hospital. Over a nine-year period, 520 emergency events were identified; 25% were cardiac arrest events and 60% occurred among patients who had been admitted for more than 48 hours. Over the nine-year period, failure to rescue events decreased from 23.6% to 2.5%.
Bennion J, Mansell SK. Br J Hosp Med (Lond). 2021;82:1-8.
Many strategies have been developed to improve recognition of, and response, to clinically deteriorating patients. This review found that simulation-based educational strategies was the most effective educational method for training staff to recognize unwell patients. However, the quality of evidence was low and additional research into simulation-based education is needed.
Bernstein SL, Kelechi TJ, Catchpole K, et al. Worldviews Evid Based Nurs. 2021;18:352-360.
Failure to rescue, the delayed or missed recognition of a potentially fatal complication that results in the patient’s death, is particularly tragic in obstetric care. Using the Systems Engineering Initiative for Patient Safety (SEIPS) framework, the authors describe the work system, process, and outcomes related to failure to rescue, and develop intervention theories.
Curated Libraries
September 13, 2021
Ensuring maternal safety is a patient safety priority. This library reflects a curated selection of PSNet content focused on improving maternal safety. Included resources explore strategies with the potential to improve maternal care delivery and outcomes, such as high reliability, collaborative initiatives, teamwork, and trigger tools.
WebM&M Case August 25, 2021

A seven-year-old girl with esophageal stenosis underwent upper endoscopy with esophageal dilation under general anesthesia. During the procedure, she was fully monitored with a continuous arterial oxygen saturation probe, heart rate monitors, two-lead electrocardiography, continuous capnography, and non-invasive arterial blood pressure measurements.

Fischer CP, Bilimoria KY, Ghaferi AA. JAMA. 2021;326:179-180.
Rapid response teams (RRTs) are intended to quickly identify clinical deterioration and prevent intensive care unit transfer, cardiac arrest, or death. This article summarizes the evidence included in the AHRQ Making Healthcare Safer III report about the use of RRTs to decrease failure to rescue. Although utilization is widespread, the authors conclude that definitive evidence that RRTs are associated with reduced rates of failure to rescue is inconclusive. The authors note that evidence does support that RRTs are associated with reduced secondary outcomes, such as ICU transfer rate and cardiac arrest.
Bates DW, Levine DM, Syrowatka A, et al. NPJ Digit Med. 2021;4:54.
Artificial Intelligence (AI) is used across healthcare settings to address a variety of patient safety targets. This scoping review evaluated the potential of AI to improve patient safety across eight domains including adverse drug events, decompensation, and diagnostic errors. Both traditional (e.g. EHR) and novel (e.g. wearables) data sources can be used to develop models and interventions to improve patient safety.
Bacon CT, McCoy TP, Henshaw DS. J Nurs Adm. 2021;51(1) :12-18.
Lack of communication and interpersonal dynamics can contribute to failure to rescue. This study surveyed 262 surgical staff about perceived safety climate, but the authors did not find an association between organizational safety culture and failure to rescue or inpatient mortality.  
Dykes PC, Lowenthal G, Faris A, et al. J Patient Saf. 2021;17:56-62.
Failure to rescue – the lack of adequate response to patient deterioration – has been associated with adverse patient outcomes, particularly in acute care settings. This article describes two health systems’ efforts to implement in-hospital Clinical Monitoring System Technology (CMST) which positively impacted failure-to-rescue events. The authors identified barriers and facilitators to CMST use, which informed the development of an implementation toolkit addressing readiness, implementation, patient/family introduction, champions, and troubleshooting. 

Hannenberg AA, ed. Anesthesiol Clin. 2020;38(4):727-922.

Anesthesiology critical events are uncommon, and yet they have great potential for harm. This special issue focuses on management of, and preparation for, perioperative critical events and rescue should they occur. The authors highlight simulation training, debriefing, and cognitive aids as methods for improving safety in the operating room.
Lin D, Peden CJ, Langness SM, et al. Anesth Analg. 2020;131:e155-1159.
The anesthesia community has been a leader in patient safety innovation for over four decades. This conference summary highlights presented content related to the conference theme of “preventing, detecting, and mitigating clinical deterioration in the perioperative period.” The results of a human-centered design analysis exploring tactics to reduce failure to rescue were summarized.
Burke JR, Downey C, Almoudaris AM. J Patient Saf. 2022;18:e140-e155.
This systematic review identified three critical points that can contribute to “failure to rescue” among inpatients with serious complications – (1) failure to recognize the complications; (2) failure to relay information regarding the complications to the care team, and; (3) failure to react in a timely and appropriate manner to the patient’s deterioration. Effective tools and interventions which can be implemented during each timepoint are discussed, including increased nurse staffing, rapid response teams, checklists, and early warning score systems.
Perspective on Safety March 30, 2020
This perspective discusses the Making Healthcare Safer Report, what is new in the recently released third edition, and how the report can be used.
This perspective discusses the Making Healthcare Safer Report, what is new in the recently released third edition, and how the report can be used.
An Gaffey
Ann D. Gaffey, RN, MSN, CPHRM, DFASHRM is the President of Healthcare Risk and Safety Strategies, LLC. Bruce Spurlock, MD is the President and CEO of Cynosure Health. We spoke with them about their role in the development of the Making Healthcare Safer III Report and what new information they think audiences will find particularly useful and interesting.
Cho K-J, Kwon O, Kwon J-myoung, et al. Crit Care Med. 2020;48:e285-e289.
This study compared an artificial intelligence (AI)-based early warning system using machine learning with conventional trigger methods for predicting deterioration among hospitalized patients, defined as in-hospital cardiac arrest resulting in ICU admissions. The AI system accurately predicted deterioration and was more accurate than conventional methods, demonstrating its potential effectiveness in EHR-based rapid response systems.

Holmes A, Long A, Wyant B, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2020. AHRQ Publication No. 20-0029-EF.

This newly issued follow up to the seminal AHRQ Making Health Care Safer report (first published in 2001 and updated in 2013 critically examines the evidence supporting 47 separate patient safety practices chosen for the high-impact harms they address. It includes diagnostic errors, failure to rescue, sepsis, infections due to multi-drug resistant organisms, adverse drug events and nursing-sensitive conditions. The report discusses the evidence on cross-cutting safety practices, including safety culture, teamwork and team training, clinical decision support, patient and family engagement, cultural competency, staff education and training, and monitoring, audit and feedback. The report provides recommendations for clinicians and decision-makers on effective patient safety practices.
Bacon CT, McCoy TP, Henshaw DS. Res Nurs Health. 2019.
This study assessed the impact of crew resource management (CRM) training for surgical staff and organizational leadership on failure to rescue and 30-day in-hospital mortality. Two hospitals within a larger tertiary care system participated – one received training, the other did not. The authors found that the odds of FTR (2.9%) and 30-day mortality (0.4%) were higher at the hospital that received CRM training, but these differences were not statistically significant. These findings are consistent with prior research which found that CRM improved staff outcomes, such as safety culture and situational awareness, rather than patient-related outcomes.
Koers L, van Haperen M, Meijer CGF, et al. JAMA Surg. 2019;155:e194704.
Failure to rescue is a significant cause of morbidity and mortality and is often associated with human error. In this innovative study, the authors posit that the use of cognitive aids, which are prompts that can help practitioners’ complete evidence-based tasks (e.g. symptom-specific checklists, flowcharts, and clinical guidelines), could improve timely recognition and effective management of complications in a surgical population. The study randomized surgeons and nurses to manage deteriorating patients in simulated scenarios with or without the use of cognitive aids. Use of cognitive aids significantly reduced omitted critical management steps and failure to adhere to best practices.  
Patient Safety Primer September 7, 2019
Failure to rescue is both a concept and a measure of hospital quality and safety. The concept captures the idea that systems should be able to rapidly identify and treat complications when they occur, while the measure has been defined as the inability to prevent death after a complication develops.