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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 - 14 of 14 Results
Petrosoniak A, Fan M, Hicks CM, et al. BMJ Qual Saf. 2021;30:739-746.
Trauma resuscitation is a complex, specialized process with a high risk for errors. Researchers analyzed videotapes of in situ simulations to evaluate latent safety events occurring during trauma resuscitation. Themes influencing latent safety events related to physical workspace, mental model formation, equipment, unclear accountability, demands exceeding individuals’ capacity, and task-specific issues.
Stokke R, Melby L, Isaksen J, et al. BMC Health Serv Res. 2021;21:553.
This article explored the interface of technology and patients in home care. Researchers identified three work processes that contribute to patient safety: aligning people with technologies, being alert and staying calm, and coordinating activities based on people and technology. Topics for future research should include the division of labor on home care shifts, the need for new routines and education in telecare for care workers, and how decisions are made regarding home technology.
Keen J, Abdulwahid MA, King N, et al. BMJ Open. 2020;10:e036608.
Health information technology has the potential to improve patient safety in both inpatient and outpatient settings. This systematic review explored the effect of technology networks across health systems (e.g., linking patient records across different organizations) on care coordination and medication reconciliation for older adults living at home. The authors identified several barriers to use of such networks but did not identify robust evidence on their association with safety-related outcomes.
Pelaccia T, Messman AM, Kline JA. Patient Edu Couns. 2020;103:1650-1656.
The hectic and complex environment of emergency care can reduce diagnostic safety. This article discusses clinical reasoning and decision-making strategies used by emergency medicine physicians, contributing factors to diagnostic errors occurring in emergency medicine (e.g., overconfidence, cognitive stress, anchoring bias), and strategies to reduce the risk of error. A previous WebM&M commentary discussed an incident involving diagnostic delay in the emergency department.

Herd P, Moynihan D. Health Affairs Health Policy Brief. October 2, 2020.

The crossover of health equity concepts to patient safety has emerged as a consideration for improvement. This policy brief examines how administrative burdens can separate patients from the care they need and calls for increased attention to the problem.  
Deacon A, O’Neill T, Delaloye N, et al. Hosp Pediatr. 2020;10:758-766.
This qualitative study used a resuscitation simulation to explore the effect of family presence during resuscitation on team performance. Thematic analyses identified five key factors that are influenced by the presence of a parent during resuscitation – resuscitation environment, affective responses, cognitive responses, behavioral responses, and team dynamics.

ISMP Medication Safety Alert! Acute care edition. September 10, 2020;25(18)

This alert discusses medication errors that have been reported to the Food and Drug Administration involving the preparation, administration, and storage of two formulations of the investigational COVID-19 treatment remdesivir. Recommendations to guide safe practice include use of standard order sets and dosing clarifications.
Choudhury A, Asan O. JMIR Med Inform. 2020;8:e18599.
This systematic review explored how artificial intelligence (AI) based on machine learning algorithms and natural language processing is used to address and report patient safety outcomes. The review suggests that AI-enabled decision support systems can improve error detection, patient stratification, and drug management, but that additional evidence is needed to understand how well AI can predict safety outcomes.  
Fraczkowski D, Matson J, Lopez KD. J Am Med Inform Assoc. 2020;27:1149-1165.
The authors reviewed studies using qualitative and quantitative methods to describe nursing workarounds related to the electronic health record (EHR) in direct care activities. Workarounds generally fit into three categories – omission of process steps, steps performed out of sequence, and unauthorized process steps. Probable causes for workarounds were identified, including organizational- (e.g., knowledge deficits, non-formulary orders), environmental-, patient- (e.g., barcode/ID not accessible), task- (e.g., insufficient time), and usability-related factors (e.g., multiple screens to complete an action). Despite nurses being the largest workforce using EHRs, there is limited research focused on the needs of nurses in EHR design.
Fortman E, Hettinger AZ, Howe JL, et al. J Am Med Info Assoc. 2020;27:924-928.
Physicians from different health systems using two computerized provider order entry (CPOE) systems participated in simulated patient scenarios using eye movement recordings to determine whether the physician looked at patient-identifying information when placing orders. The rate of patient identification overall was 62%, but the rate varied by CPOE system. An expert panel identified three potential reasons for this variation – visual clutter and information density, the number of charts open at any given time, and the importance placed on patient identification verification by institutions.  
Weingart SN, Yaghi O, Barnhart L, et al. Appl Clin Inform. 2020;11.
To decrease the risk of diagnostic errors attributed to incomplete recommended diagnostic tests, this study evaluated an electronic monitoring tool alerting clinicians to incomplete imaging tests for their ambulatory patients. Compared to the control group (physicians not receiving alerts for their patients), after 90-days the intervention group had a higher rate of imaging completion (22.1% vs. 18.8%); this difference was sustained throughout the 12-month follow-up period (25.5% completion in the intervention group versus 20.9% in the control group). The authors found that this change was primarily driven by completion rates among patients referred for mammography.  To fully appreciate the implications of missed test notifications to reduce the risk of delayed diagnoses, more studies are necessary.
Isbell LM, Boudreaux ED, Chimowitz H, et al. BMJ Qual Saf. 2020;29:815–825.
Research has suggested that health care providers’ emotions may impact patient safety. These authors conducted 86 semi-structured interviews with emergency department (ED) nurses and physicians to better understand their emotional triggers, beliefs about emotional influences on patient safety, and emotional management strategies. Patients often triggered both positive and negative emotions; hospital- or systems-level factors primarily triggered negative emotions. Providers were aware that negative emotions can adversely impact clinical decision-making and place patients at risk; future research should explore whether emotional regulation strategies can mitigate these safety risks.
Becker RE. J Patient Saf. 2020;16.
This commentary explores two scientific cultures in modern medicine. A ‘traditional culture’ leaves error control up to individuals and groups of healthcare practitioners; the author describes how this culture leads to an overconfidence among practitioners about personal abilities to reduce errors. In contrast, a ‘modern scientific culture’ considers errors as inevitable and pervasive throughout medicine and beyond individuals or groups to control. The author describes the competing priorities of these cultures, and suggests that error control efforts in medicine will be more successful if there is a paradigm shift towards a more ‘modern’ attitude.
Song Y, Hoben M, Norton PG, et al. JAMA Netw Open. 2020;3.
The authors surveyed over 4,000 care aids from 93 urban nursing homes in Western Canada to assess the association of work environment with missed and rushed essential care tasks. During their most recent shift, over half of care aids (57.4%) reported missing at least one essential care task and two-thirds (65.4%) reported rushing at least one essential care task. Work environments with better work culture and more effective leadership were associated with fewer missed or rushed care tasks.