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 55 Results

Examining the meaning of the language used to communicate the nursing hand-off.

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Galatzan BJ, Carrington JM. Res Nurs Health. 2021;44:833-843.

During handoffs, nurses are exposed to a variety of interruptions and distractions which may lead to cognitive overload. Using natural language processing, researchers analyzed ten audio-recorded change of shift handoffs to estimate the cognitive load experienced by nurses. Nurses’ use of concise language has the potential to decrease cognitive overload and improve patient outcomes.

Influence of perioperative handoffs on complications and outcomes.

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Burden AR, Potestio C, Pukenas E. Adv Anesth. 2021;39:133-148.

Handoffs occur several times during a perioperative encounter, increasing the risk of communication errors. Structured handoffs, such as situation-background-assessment-recommendation (SBAR) and checklists, have been shown to improve communication between providers during anesthesia care. The authors discuss how these tools and other processes can improve shared understanding of effective handoffs.

It's like sending a message in a bottle: a qualitative study of the consequences of one-way communication technologies in hospitals.

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Lafferty M, Harrod M, Krein SL, et al. J Am Med Inform Assoc. 2021;28:28(12).

Use of one-way communication technologies, such as pagers, in hospitals have led to workarounds to improve communication. Through observation, shadowing, interviews, and focus groups with nurses and physicians, this study describes antecedents, types, and effects of workarounds and their potential impact on patient safety.

Curated Libraries

Maternal Safety

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.

Unlocking Solutions in Imaging: Working Together to Learn from Failings in the NHS.

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London, UK: Parliamentary and Health Service Ombudsman; 2021. ISBN 9781528627016.

Lack of appropriate follow up of diagnostic imaging can result in care delays, patient harm, and death. This report summarizes an investigation of 25 imaging failures in the British National Health Service (NHS). The analysis identified communication and coordination issues resulting in lack of action and reporting of unanticipated findings to properly advance care. Recommendations to improve imaging in the NHS include use of previous analyses to enhance learning from failure.

Disparate perspectives: exploring healthcare professionals' misaligned mental models of older adults' transitions of care between the emergency department and skilled nursing facility.

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Werner NE, Rutkowski RA, Krause S, et al. Appl Ergon. 2021;96:103509.

Shared mental models contribute to effective team collaboration and communication. Based on interviews and thematic analysis, the authors explored mental models between the emergency department (ED) and skilled nursing facility (SNF). The authors found that these healthcare professionals had misaligned mental models regarding communication during care transitions and healthcare setting capability, and that these misalignments led to consequences for patients, professionals, and the organization.

Missed nursing care during the COVID-19 pandemic: a comparative observational study.

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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.

The perfect storm: exam of a medical error and factors contributing to its possible escalation.

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Walters GK. J Patient Saf. 2021;17:e264-e267.

The majority of preventable adverse events are multifactorial in nature and are a result of system failures. Using a case study, the authors outline a series of errors following misplacement of a PICC line. Failures include differences in recording electronic health record notes and communication between providers. Investigations of all adverse events will help identify and correct system failures to improve patient safety.

An observational study of postoperative handoff standardization failures.

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Abraham J, Meng A, Sona C, et al. Int J Med Inform. 2021;151:104458.

Standardized handoff protocols from the operating room to the intensive care unit have improved patient safety, but clinician compliance and long-term sustainability remain poor. This study identified four phases of post-operative handoff associated with risk factors: pre-transfer preparation, transfer and set up, report preparation and delivery, and post-transfer care. The authors recommend “flexibly standardized” handoff intervention tools for safe transfer from operating room to intensive care.

Facilitators and barriers of care transitions - comparing the perspectives of hospital and community healthcare staff.

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Carman E-M, Fray M, Waterson P. Appl Ergon. 2021;93:103339.

This study analyzed incident reports, discharge planning meetings, and focus groups with hospital and community healthcare staff to identify barriers and facilitators to safe transitions from hospital to community. Barriers included discharge tasks not being complete, missing or inaccurate information, and limited staff capacity. Facilitators include improved staff capacity and good communication between hospital staff, community healthcare staff, and family members. The authors recommend that hospital and community healthcare staff perspectives be taken into account when designing safe discharge policies.

Project BOOST Increases Patient Understanding of Treatment and Follow-up Care

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Patient Safety Innovation May 26, 2021

The Patient Safe-D(ischarge) program used standardized tools to educate patients about their discharge needs, test understanding of those needs, and improve medication reconciliation at admission and discharge. A quasi-randomized controlled trial of the program found that it significantly increased patients' understanding and knowledge of their diagnoses, treatment, and required follow-up care.

Strategies to prevent missed nursing care: an international qualitative study based upon a positive deviance approach.

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Longhini J, Papastavrou E, Efstathiou G, et al. J Nurs Manag. 2021;29:572-583.

This international qualitative study explored strategies employed by nurse managers and directors to prevent missed nursing care. Most strategies, including staffing ratios, communication, and empowering nurse leaders, required complex interventions at the system level, indicating missed nursing care is not merely a nursing issue. Nurse managers play a key role in implementing strategies at the nursing and hospital level.

I-PASS handover system: a decade of evidence demands action.

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Shahian DM. BMJ Qual Saf. 2021;30:769-774.

The I-PASS structured handoff tool aims to improve communication during patient transfers and reduce errors and preventable adverse events. This editorial summarizes evidence supporting I-PASS implementation and the challenge of rigorously assessing the association between handoffs and adverse events, medical errors, and other clinical outcomes.

Self-Reported Learning (SRL), a voluntary incident reporting system experience within a large health care organization.

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Lurvey LD, Fassett MJ, Kanter MH. Jt Comm J Qual Patient Saf. 2021;47:288-295.

High reliability organizations encourage staff to self-report errors and hazards for comprehensive review and improvement. Three hospitals in one health system implemented a voluntary error reporting system for clinicians to report their own and others’ clinical errors. Although only 5% of reported errors were physician self-reports, there were still benefits: it captured novel errors, provided a safe space to report those errors, and encouraged secondary insights into causes of the errors.

Interprofessional training and communication practices among clinicians in the postoperative ICU handoff.

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Massa S, Wu J, Wang C, et al. Jt Comm J Qual Patient Saf. 2021;47:242-249.

The objective of this mixed methods study was to characterize training, practices, and preferences in interprofessional handoffs from the operating room to the intensive care unit (OR-to-ICU). Anesthesia residents, registered nurses, and advanced practice providers indicated that they had not received enough preparation for OR-to-ICU handoffs in their clinical education or on-the-job training. Clinicians from all professions noted a high value of interprofessional education in OR-to-ICU handoffs, especially during early degree programs would be beneficial.

Nurse work environment and its impact on reasons for missed care, safety climate, and job satisfaction: a cross-sectional study.

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Dutra CK dos R, Guirardello E de B. J Adv Nurs. 2021;77:2398-2406.

This cross-sectional study describes the relationship between nurse work environment and missed nursing care, safety culture, and job satisfaction. Nurses who perceived a positive work environment reported reduced reasons for missed nursing care, an improved safety culture, and increased job satisfaction. Reasons for missed care were primarily related to lack of leadership support and resources. Nurse managers can increase perception of a positive work environment by providing additional support and adequate human and material resources.

From fable to reality at Parkland Hospital: the impact of evidence-based design strategies on patient safety, healing, and satisfaction in an adult inpatient environment.

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Rich RK, Jimenez FE, Puumala SE, et al. HERD. 2020;14:65-82.

Design changes in health care settings can improve patient safety. In this single-site study, researchers found that new hospital design elements (single patient acuity-adaptable rooms, decentralized nursing stations, access to nature, etc.) improved patient satisfaction but did not impact patient outcomes such as length, falls, medication events, or healthcare-associated infections.

Code Status vs. Care Status

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WebM&M Case December 23, 2020

A 65-year-old man with metastatic cancer and past medical history of schizophrenia, developmental delay, and COPD was admitted to the hospital with a spinal fracture. He experienced postoperative complications and continued to require intermittent oxygen and BIPAP in the intensive care unit (ICU) to maintain oxygenation. Upon consultation with the palliative care team about goals of care, the patient with telephonic support of his long time caregiver, expressed his wish to go home and the palliative care team, discharge planner, and social services coordinated plans for transfer home. Altho

Society for Maternal-Fetal Medicine Special Statement: a maternal transport briefing form and checklist.

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Gibson KS, McLean D. Am J Obstet Gynecol. 2020;223:B12-B15.

Patient transport is vulnerable to a range of errors that can affect patient care. This guidance explores the use of a checklist to standardize team communication and coordination during maternal transport between two locations.

Factors influencing physician responsiveness to nurse-initiated communication: a qualitative study.

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Manojlovich M, Harrod M, Hofer TP, et al. BMJ Qual Saf. 2021;30:747-754.

Communication failures can lead to patient harm. Based on observations, interviews, and focus groups with nurses and physicians, the authors found that physician responsiveness to communications from bedside nurses depends on a combination of factors including the clarity of the message, physician preference for one communication via text, page, phone call, and other factors, such as trust, interpersonal relationships, and different clinical perspectives.

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