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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 80 Results

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.
Cecil E, Bottle A, Majeed A, et al. Br J Gen Pract. 2021;71:e547-e554.
There has been an increased focus on patient safety, including missed diagnosis, in primary care in recent years. This cohort study evaluated the incidence of emergency hospital admission within 3 days of a visit with a GP with missed sepsis, ectopic pregnancy, urinary tract infection or pulmonary embolism. Shorter duration of appointment and telephone appointment (compared with in person) were associated with increased incidence of self-referred emergency hospital admission.
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.
von Vogelsang A‐C, Göransson KE, Falk A‐C, et al. J Nurs Manag. 2021;29:2343-2352.
Incomplete nursing care can be detrimental to care quality and patient safety. This cross-sectional survey of nurses in Sweden at one acute care hospital did not identify significant differences in missed nursing care before and during the COVID-19 pandemic. The authors posit that these results may be attributed to maintaining nurse-patient ratios, sufficient nursing skill mix, and patient mix.
Holden RJ, Carayon P. BMJ Qual Saf. 2021;30:901-910.
Since the SEIPS (Systems Engineering Initiative for Patient Safety) conceptual model was introduced in 2006, several additional versions have been introduced. In this commentary, the authors of SEIPS 2.0 and SEIPS 3.0 present a practice-oriented SEIPS model (SEIPS 101) along with seven simple tools for use by practitioners, researchers, and others.
Komashie A, Ward JR, Bashford T, et al. BMJ Open. 2021;11:e037667.
A systems approach is a key element in safe patient care. This systematic review concluded that a systems approach to healthcare design and delivery can lead to significant improvements in patient and service outcomes (e.g., fewer delays for appointments and time-to-treatment).  
Hedsköld M, Sachs MA, Rosander T, et al. BMC Health Serv Res. 2021;21:48.
Intensive care units (ICUs) are complex environments that carry high risk for medical errors. This qualitative study characterized the role of front-line ICU managers in organizing for safe care and creating a culture of safety.  
Rogith D, Satterly T, Singh H, et al. Appl Clin Inform. 2020;11:692-698.
Lack of timely follow-up of test results is a recognized patient safety problem in primary care and can lead to missed or delayed diagnoses. This study used human factors methods to understand lack of timely follow-up of abnormal test results in outpatient settings. Through interviews with the ordering physicians, the researchers identified several contributing factors, such as provider-patient communication channel mismatch and diffusion of responsibility.
Temkin-Greener H, Cen X, Li Y. Gerontologist. 2020;60:1303-1311.
Nurse staffing is an important factor in maintaining patient safety. In this study, the Nursing Home Survey on Patient Safety Culture was used to assess the association of registered nurse (RN) and certified nurse assistant (CNA) turnover on perceived patient safety culture. Results indicate that CNA turnover is associated with lower patient safety culture scores, but RN turnover is not. The authors conclude that patient safety culture improvements in nursing homes may be dependent on retaining a well-trained and skilled nursing staff.
Patel AG, Pizzitola VJ, Johnson CD, et al. Radiology. 2020;297:374-379.
The authors analyzed CT interpretation errors committed by radiology fellows working off-hours over a four-year period and found that interpretation errors occurred more frequently at night and in the latter half of night assignments.  
WebM&M Case June 24, 2020
A 55-year old woman became unarousable with low oxygen saturation as a result of multiple intravenous benzodiazepine doses given overnight. The benzodiazepine was ordered following a seizure in the intensive care unit (ICU) and was not revised or discontinued upon transfer to the floor; several doses were given for different indications - anxiety and insomnia.
Sweet W, Snyder D, Raymond M. J Healthc Risk Manag. 2020;40:44-49.
This article describes one health system’s experience implementing an infection prevention program into risk management in an outpatient setting. Over a two-year period post-implementation, the system identified and corrected high-risk practices, increased compliance to device guidance, increased efficiency with the use of central sterile processing departments, and developed a staff competency training structure.
Cinar P, Kubal T, Freifeld A, et al. J Natl Compr Canc Netw. 2020;18:504-509.
This article reviews strategies to mitigate transmission of COVID-19 among patients with cancer and for the healthcare workers providing care to those patients. The authors recommend several approaches ensure patient safety, including COVID-19 prescreening/screening via telemedicine, greater utilization of tele-oncology, limiting surgeries and procedures to only essential, urgent, or emergent cases, and switching therapies to oral (versus infusion) when possible. They also propose measures focused on healthcare worker safety, including appropriate use of personal protective equipment (PPE), use of daily screening tools and/or temperature checks, greater use of telework and limited onsite staff, and clear stay-at-home and return-to-work guidelines.
Lagoo J, Berry WR, Henrich N, et al. Jt Comm J Qual Patient Saf. 2020;46:314-320.
As part of a quality improvement initiative to enhance surgical onboarding, the authors used semi-structured interviews with 20 physicians to understand potential areas of risk when a physician begins working in an unfamiliar setting. Qualitative analysis found that three key findings: (1) physicians often receive little to no onboarding when starting to practice in a new setting, which can limit their ability to provide safe care; (2) physicians felt onboarding inadequately fostered strong interpersonal relationships among health care teams, which impedes psychological safety and team cohesion, and; (3) physicians noted an increased risk of patient harm during emergency situations in new settings due to lack of understanding of culture, workflow, roles/responsibilities and available equipment.
WebM&M Case February 26, 2020
This commentary involves two separate patients; one with a missing lab specimen and one with a mislabeled specimen. Both cases are representative of the challenges in obtaining and appropriately tracking lab specimens and the potential harms to patients. The commentary describes best practices in managing lab specimens.
Härkänen M, Vehviläinen‐Julkunen K, Murrells T, et al. J Nurs Scholarsh. 2019;52:113-123.
This retrospective study used descriptive statistics, manual analysis, and text mining of medication-related incident reports and staffing (N = 72,390) in England and Wales. The text mining was conducted with SAS Text Minor tool.  Effective trigger terms included “short staffing”, “workload”, and “extremely busy”.  The authors concluded that inadequate staffing, workload, and working in haste may increase the risk for errors.  The key importance of this article is the use of an automated system to analyze incident reports.
Neprash HT, Barnett ML. JAMA Netw Open. 2019;2:e1910373.
The root causes of the opioid epidemic are complex, but inappropriate prescribing of opioids (which includes both prescribing opioids in situations where they are not indicated as well as excessive prescribing for appropriate indications) is a major contributor. Prior studies of outpatient antibiotic prescribing have shown that rates of inappropriate prescribing rise toward the end of clinicians' clinic sessions. This cross-sectional study used data from 5603 primary care physicians for acute painful conditions to analyze whether a similar relationship exists for opioid prescribing. Investigators found that the likelihood of opioid prescribing rose considerably as the workday progressed; clinicians were also more likely to prescribe opioids if their appointments were running late. In contrast, prescriptions for nonopioid therapies did not change in relation to appointment time. Although the magnitude of these effects was smaller than the variation in opioid prescribing rates between physicians found in other studies, these findings confirm that production pressure and decision fatigue contribute to inappropriate prescribing and should be addressed in quality improvement efforts to reduce opioid use.
Nakhleh RE, Volmar KE, eds. Cham, Switzerland: Springer Nature; 2019. ISBN: 9783030184636.
Surgical specimen and laboratory process problems can affect diagnosis. This publication examines factors that contribute to errors across the surgical pathology process and reviews strategies to reduce their impact on care. Chapters discuss areas of focus to encourage process improvement and error response, such as information technology, specimen tracking, root cause analysis, and disclosure.
Sherman J, Hedli LC, Kristensen-Cabrera AI, et al. Am J Perinatol. 2020;37:638-646.
This direct observation study examined maternal and neonatal care at 10 labor and delivery units. Investigators uncovered three environmental needs that impact safety: rapid access to blood products, space for neonatal resuscitation, and organization and availability of equipment and supplies. They conclude that applying design thinking to physical space could improve maternal and neonatal safety.