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 141 - 160 of 18110 Results

Surveys on Patient Safety Culture Nursing Home Survey: 2023 User Database Report.

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Hare R, Tyler ER, Tapia A, et al. Rockville, MD: Agency for Healthcare Research and Quality; January 2023. AHRQ Publication No. 23-0018.

The AHRQ Surveys on Patient Safety Culture™(SOPS®) Nursing Home Survey assesses safety culture and resident safety in nursing homes. This report summarizes survey data from 3,224 staff working in 62 nursing homes. Respondents reported positive perceptions about both resident safety overall and feedback and communication regarding safety incidents. Areas for improvement included sufficient staffing to handle the workload and maintain resident safety.

Insurance claims for wrong-side, wrong-organ, wrong-procedure, or wrong-person surgical errors: a retrospective study for 10 years.

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Vacheron C-H, Acker A, Autran M, et al. J Patient Saf. 2023;19:e13-e17.

Wrong-site, wrong-procedure, and wrong-patient errors (WSPEs) are serious adverse events. This retrospective analysis of medical liability claims data examined the incidence of WSPEs in France between 2007 and 2017. During this ten-year period, WSPEs accounted for 0.4% of all claims. Procedures on the wrong organ were most common (44%), followed by wrong side (39%), wrong person (13%) and wrong procedure (4%). The researchers found that the average number of WSPEs decreased after implementation of a surgical checklist.

Using automated methods to detect safety problems with health information technology: a scoping review.

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Surian D, Wang Y, Coiera E, et al. J Am Med Inform Assoc. 2022;30:382-392.

Health information technology (HIT), such as electronic health records (EHRs) or computerized provider order entry (CPOE) systems, are important approaches to improving safety. This scoping review of 45 articles found that machine learning and statistical modeling are the most commonly used automated, HIT-based methods for early detection of safety threats. Machine learning was often used to detect errors occurring in laboratory test results, prescriptions, and patient records. Statistical modeling was used to detect issues with clinical decision support systems.

A scoping review of adverse incidents research in aged care homes: learnings, gaps, and challenges.

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St Clair B, Jorgensen M, Nguyen A, et al. Gerontol Geriatr Med. 2022;Epub Dec 20.

Older adults in long-term care settings can be vulnerable to patient safety incidents. This scoping review of 46 articles identified several gaps in the research on adverse events in long-term care and nursing home settings, including the absence of resident perspectives regarding safety and the role of interpersonal and environmental factors on the incidence of adverse events.

Using trainee failures to enhance learning: a qualitative study of pediatric hospitalists on allowing failure.

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Klasen JM, Beck J, Randall CL, et al. Acad Pediatr. 2023;23:489-496.

As part of clinical learning, residents and trainees are sometimes allowed to make supervised mistakes when patient safety is not at risk. In this study, pediatric hospitalists describe potential benefits and risks of allowing failure, the process of allowing or interrupting failure, and how they decide to allow failure to happen. Consistent with previous research, patient, trainee, team, and institutional factors were identified. Additionally, caregiver/parent factors were noted.

Patient safety culture: the impact on workplace violence and health worker burnout.

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Kim S, Kitzmiller R, Baernholdt MB, et al. Workplace Health Saf. 2022;71:78-88.

Physical and verbal violence against healthcare workers has been identified as a sentinel event by the Joint Commission. In this secondary analysis of survey data on workplace violence (WPV), researchers explored which attributes of patient safety culture may predict healthcare workers’ experiences of WPV and burnout. Better teamwork and staffing were among the attributes associated with lower risk of WPV.

The woman who cried pain: do sex-based disparities still exist in the experience and treatment of pain?

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Hoffmann DE, Fillingim RB, Veasley C. J Law Med Ethics. 2022;50:519-541.

Women’s pain has been underestimated compared to men’s pain, and treatments differ based on gender. This commentary revisits the findings from the 2001 article The Girl Who Cried Pain: A Bias Against Women in the Treatment of Pain. The authors state progress has been made in the past 20 years, but disparities still exist. Additional research is needed, particularly into chronic pain conditions that are more common in women.

Effect of contextual factors on the prevalence of diagnostic errors among patients managed by physicians of the same specialty: a single-centre retrospective observational study.

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Harada Y, Otaka Y, Katsukura S, et al. BMJ Qual Saf. 2023;Epub Jan 23.

Context, such as patient, clinician, location, or specialty, can affect the type and frequency of diagnostic errors. In this novel study, the diagnostic errors of a cohort of clinicians who practice in multiple locations (i.e., outpatient and emergency department) with different referral types (i.e., scheduled visit, urgent visit, emergency visit) was evaluated. Using the Revised Safer Dx instrument, researchers identified significantly more diagnostic errors in patients with scheduled visits compared to urgent or emergent referrals. The results indicate, that among clinicians in the same specialty, it may be contextual factors (i.e., referral type) that affect diagnostic errors rather than specialty.

In situ simulation: a strategy to restore patient safety in intensive care units after the COVID-19 pandemic?

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Gómez-Pérez V, Escrivá Peiró D, Sancho-Cantus D, et al. Healthcare (Basel). 2023;11:263.

The redeployment of clinicians at the beginning of the COVID-19 public health emergency necessitated rapid training of staff, particularly those assigned to the intensive care unit (ICU). This review identified effective in-situ simulations that could be used in ICUs to restore and sustain patient safety following the COVID-19 pandemic. The in-situ simulations were able to detect latent safety threats and improve patient safety culture, interprofessional communication, and system organization.

‘Ladder’-based safety culture assessments inversely predict safety outcomes.

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Boskeljon‐Horst L, Sillem S, Dekker SWA. J Contingencies Crisis Manag. 2022;Epub Dec 27.

High-reliability organizations frequently assess the strength of their safety culture. In this article, researchers compare the results of a safety culture assessment (SCA) of a helicopter squadron and investigation of an accident that occurred shortly after survey administration. Results of the SCA showed the safety culture was mature, but the investigation revealed otherwise, indicating the SCA had little predictive value.

Race and socioeconomic bias in pediatric cardiac transplantation.

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Amdani S, Conway J, Kleinmahon J, et al. JACC Heart Fail. 2023;11:19-26.

Research has shown clinicians frequently have implicit biases against patients of color, women, and transgender patients. This study used Implicit Association Tests (IAT) to evaluate implicit bias in pediatric heart transplant clinicians. Results showed these clinicians had a bias, or preference for, individuals who were White, from a higher socio-economic group, and had more education. These results are similar to other adult and pediatric clinicians.

A customized triggers program: a children's hospital's experience in improving trigger usability.

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Reinhart RM, Safari-Ferra P, Badh R, et al. Pediatrics. 2023;151:e2022056452.

Trigger tools are widely used for detecting potential adverse events among adult and pediatric inpatients. This article describes the development of a pediatric triggers program that can identify potential adverse events in near real-time to facilitate appropriate preventative measures. The tool includes criteria from the IHI Global Trigger Tool as well as novel triggers (such as pain reassessment time, hospital readmissions, and suspected sepsis). The trigger team created a process for linking triggers to the organizational incident reporting system based on specific criteria (to reduce false-positive reports). The trigger team is continuously developing and refining triggers based on stakeholder input.

Fellowships and Mentorships Program.

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Institute for Safe Medication Practices.

These educational programs with the Institute for Safe Medication Practices (ISMP) are for clinicians who wish to expand their practical knowledge of medication error prevention. The application process for the 2023-2024 fellowships will close May 16, 2023.

National Safety Standards for Invasive Procedures (NatSSIPs2).

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Centre for Perioperative Care. London, UK; January 2023.

Patients face risks when undergoing surgery. This revised guidance provides recommendations developed by multidisciplinary consensus and outlines how organizations can implement the standards to improve safety of invasive procedures. The report is centered on areas of effort targeting both organizational and process-level actions.

Leadership behavior associations with domains of safety culture, engagement, and healthcare worker well-being.

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Tawfik DS, Adair KC, Palassof S, et al. Jt Comm J Qual Patient Saf. 2023;49:156-165.

Leadership across all levels of a health system plays an important role in patient safety. In this study, researchers administered the Safety, Communication, Operational, Reliability, and Engagement (SCORE) survey to 31 Midwestern hospitals to evaluate how leadership behaviors influenced burnout, safety culture, and engagement. Findings indicate that local leadership behaviors are strongly associated with healthcare worker burnout, safety climate, teamwork climate, workload, and intentions to leave the job.

Surgical site infection prevention: a review.

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Seidelman JL, Mantyh CR, Anderson DJ. JAMA. 2023;329:244-252.

Surgical site infections (SSIs) remain a significant cause of preventable post-operative morbidity and mortality. This narrative review summarizes modifiable and nonmodifiable patient-related factors. It also evaluates modifiable operation-related factors associated with surgical site infections, and highlights six pre-, intra-, and postoperative strategies to reduce surgical site infections, including use of the WHO surgical safety checklist.

Untenable expectations: nurses' work in the context of medication administration, error, and the organization.

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Hawkins SF, Morse JM. Glob Qual Nurs Res. 2022;9:233339362211317.

Medication administration is a complex set of tasks completed many times per day for hospitalized patients. This study captures the turbulence of nursing work, the nursing environment, and how that impacts patient safety. The results suggest organizations should re-evaluate current attempts at improving medication administration safety and include nurses in identifying new solutions.

Cost of inpatient falls and cost-benefit analysis of implementation of an evidence-based fall prevention program.

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Dykes PC, Curtin-Bowen M, Lipsitz S, et al. JAMA Health Forum. 2023;4:e225125.

Patient falls are associated with poorer clinical outcomes, and increased costs to the health system. This study describes the economic costs of implementing the Fall Tailoring Interventions for Patient Safety (Fall TIPS) Program in eight American hospitals. Results show the Fall TIPS program reduced falls by 19%, avoiding over $14,000 of costs per 1,000 patient days.

Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts.

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WebM&M Case February 1, 2023

A 38-year-old man with end-stage renal disease (ESRD) on chronic hemodialysis was admitted for nonhealing, infected lower leg wounds and underwent a below-knee amputation. He suffered from postoperative pain at the operative stump and was treated for four days with regional nerve blocks, as well as gabapentin, intermittent intravenous hydromorphone (which was transitioned to oral oxycodone) and oral hydromorphone.

Saved by ECMO

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WebM&M Case February 1, 2023

A 27-year-old pregnant woman was diagnosed with severe pulmonary arterial hypertension at 29 weeks estimated gestational age (EGA) and admitted for elective cesarean delivery with lumbar epidural anesthesia at 36 weeks EGA. After epidural catheter placement, she suddenly became bradycardic and hypotensive, and within 3 minutes, developed pulseless electrical activity and cardiopulmonary resuscitation (CPR) began immediately. An emergent cesarean delivery was performed.

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