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.
Rapid response teams (RRT) are intended to improve the identification and management of clinically worsening hospitalized patients. This study identified an increase in RRT activations for respiratory distress at one academic hospital during the COVID-19 pandemic. The authors outline the hospital response, which included revising RRT guidelines to reduce in-room personnel, new decision-support pathways, which accounted for COVID-19 uncertainty, and expanded critical care consults for inpatient care team.
Polancich S, Hall AG, Miltner RS, et al. J Healthc Qual. 2021;43:137-144.
The COVID-19 pandemic has disrupted many aspects of health care delivery, including how hospitals prevent common hospital-acquired conditions such as pressure injuries. Based on retrospective data, the authors of this study did not identify a longitudinal increase in hospital-acquired pressure injuries between March and July 2020. The authors discuss how prior organizational efforts to reduce hospital-acquired pressure injuries allowed their hospital to quickly adapt existing workflows and processes to respond to the COVID-19 pandemic.
Panda N, Etheridge JC, Singh T, et al. World J Surg. 2021;45:1293-1296.
The World Health Organization (WHO) surgical safety checklist is widely used in surgical settings to prevent errors. This multinational panel representing multiple clinical specialties identified 16 recommendations for checklist content modification and implementation during the COVID-19 pandemic. These recommendations exemplify how the checklist can be adapted to meet urgent and emerging needs of surgical units by targeting important processes and encouraging critical discussions.
Blake JWC, Giuliano KK. AACN Adv Crit Care. 2020;31:357-363.
The COVID-19 pandemic has led to many changes in health care delivery. This article discusses one common process change – moving medical devices (such as intravenous (IV) infusion pumps) away from the bedside – and how to support nursing clinical decision-making during IV infusion therapy.
Tiao C-H, Tsai L-C, Chen L-C, et al. Qual Manag Health Care. 2021;30:61-68.
Hospitals have needed to adapt workflow processes to optimize infection control in response to the COVID-19 pandemic. This article describes the use of healthcare failure mode and effects analysis (HFMEA) 4-step model to implement preventive risk assessment and workflow management for high-risk medical procedures during the pandemic and prevention of nosocomial infections.
Kanaan AO, Sullivan KM, Seed SM, et al. Pharmacy (Basel). 2020;8:225.
The COVID-19 pandemic has affected the ability of pharmacists to ensure medication safety. This article uses case scenarios to highlight challenges encountered due to the COVID-19 pandemic that required changes in pharmacist roles. Strategies to overcome challenges related to monitoring medications used to treat patients with COVID-19, preventing errors with laboratory reporting, and managing drug shortages are discussed.
McMullen KM, Smith BA, Rebmann T. Am J Infect Control. 2020;48:1409-1411.
This commentary discusses the potential impact of the COVID-19 pandemic on infection prevention efforts and healthcare-associated infections (HAIs). The authors suggest possible increases in CLABSI and CAUTI rates as a result of COVID-19 hospitalizations due to longer length of stay, increased use of prone positioning, and changes in nursing-related practices.
Sharara-Chami R, Sabouneh R, Zeineddine R, et al. Simul Healthc. 2020;15:303-309.
Simulation training is used by hospitals to improve patient care. This article describes the use of a preparedness assessment and training intervention featuring in situ simulations followed by debriefing to prepare staff for challenges arising due to the COVID-19 pandemic. Observations and debriefings identified several latent safety threats related to infection control, leadership, and communication.
Jiménez-Pericás F, Gea Velázquez de Castro MT, Pastor-Valero M, et al. BMJ Open. 2020;10:e035238.
Isolation for infection prevention and control, albeit necessary, may result in unintended consequences for patients (e.g., less attention, suboptimal documentation and communication, higher risk of preventable adverse events [AEs]). This prospective cohort study found that the incidence of all AEs and preventable AEs were significantly higher in isolated patients compared to non-isolated patients, primarily caused by healthcare-associated infections. These findings highlight the importance of training and safety culture when providing care to patients in isolation, particularly given the expanded use of isolation due to the COVID-19 pandemic.
Kasda EM, Robson C, Saunders J, et al. J Patient Saf Risk Manag. 2020;25:156-158.
This article describes one academic medical center’s use of the Donabedian framework to rapidly identify and mitigate COVID-19 related safety concerns. This data-driven approach to systems learning is generalizable beyond the current pandemic and can be applied to other organizational changes.
This article discusses the tension between evidence generation from observational studies and rigorous randomized controlled trials to treat COVID-19 and important safety considerations, such as use of unproven therapies.
Scopetti M, Santurro A, Tartaglia R, et al. Int J Qual Health Care. 2021;33:mzaa085.
This article presents a COVID-19 infection prevention and control plan for nursing homes, emphasizing protections for healthcare professionals, prevention of infection spread among residents, management of COVID-19 cases and limiting access to visitors.
Based on a survey of hospital medicine groups at academic medical centers in the United States (conducted April 2020), the authors of this study characterized inpatient adaptations to care for non-ICU COVID-19 patients. Sites reported rapid expansion of respiratory isolation units (RIUs – dedicated units for patients with known or suspected COVID-19), an emphasis on telemedicine for patient evaluation, and implementation of approaches to minimize room entry. In addition, nearly half of responding sites reported diagnostic errors involving COVID-19 (missing non-COVID-19 diagnoses among infected patients and missing COVID-19 diagnoses in patients admitted for other reasons).
Dharamsi A, Hayman K, Yi S, et al. J Hosp Infect. 2020;105:604-607.
This article describes the use of a rapid-cycle in-situ simulation (ISS) program to facilitate identification and resolution of organizational and systems-level safety threats (i.e., latent safety threats) involving a possible COVID-19 case. Identified threats fell in four domains: personnel, personal protective equipment, supply/environment, and communication. Most participants felt better prepared to provide care after the ISS training.
McGarry BE, Grabowski DC, Barnett ML. Health Aff (Milwood). 2020;39:1812-1821.
Based on data from the CMS COVID-19 Nursing Home Database, this study found that more than 20% of nursing homes report a severe shortage of personal protective equipment (PPE) and shortage of staff; rates for staffing and PPE did not improve from May to July of 2020. Nursing homes with COVID-19 cases among residents and staff, and those with lower quality scores, were more likely to report shortages.
Capolongo S, Gola M, Brambilla A, et al. Acta Biomed. 2020;91(9-s):50-60.
Based on qualitative data gathered through hospital observations, public health webinars, and expert working groups, the authors propose ten strategies for creating critical care surge capacity and designing resilient hospital facilities to prevent and contain COVID-19 infections. Strategies include strategic site location, functional programs, heating, ventilation, air conditioning, indoor air quality, and digital innovation.
Stall NM, Jones A, Brown KA, et al. CMAJ. 2020;192:e946-e955 .
The authors conducted a retrospective study of all long-term care facilities in Ontario, Canada, to explore the association between for-profit status and the risk of COVID-19 outbreaks and deaths between March 29 and May 20, 2020. Results indicate that, compared to nonprofit facilities, for-profit status is associated with the extent of an outbreak and the number of resident deaths but not with the likelihood of an outbreak.
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.
Choi GYS, Wan WTP, Chan AKM, et al. Br J Anaesth. 2020;125:e236-e239.
This study used high-fidelity clinical simulation to replicate admission, including tracheal intubation, of a patient with suspected or known COVID-19 infection to assess the ability of healthcare teams to effectively use personal protective equipment (PPE), the use of intubation protocols and infection control guidelines. Based on observations of 11 simulations involving 44 participants, several infection control-related workflow problems and safety threats were identified, including issues with PPE donning and doffing, advance preparation of intubation and ventilation strategies, environmental protection measures, communication difficulties, and accessibility of key drugs and equipment. These findings resulted in guideline changes, modifications to the environment and implementation of workflow modifications to improve ability of staff to adhere to infection control guidelines.
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