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.
Burrus S, Hall M, Tooley E, et al. Pediatrics. 2021;148:e2020030346.
Based on analysis of four years of data submitted to the Child Health Patient Safety Organization (CHILDPSO), researchers sought to identify types of serious safety events and contributing factors. Three main groups of serious safety events were identified: patient care management, procedural errors, and product or device errors. Contributing factors included lack of situational awareness, process failures, and failure to communicate effectively.
Avery AJ, Sheehan C, Bell B, et al. BMJ Qual Saf. 2021;30:961-976.
Patient safety in primary care is an emerging focus for research and policy. The authors of this study retrospectively reviewed case notes from 14,407 primary care patients in the United Kingdom. Their analysis identified three primary types of avoidable harm in primary care – problems with diagnoses, medication-related problems, and delayed referrals. The authors suggest several methods to reduce avoidable harm in primary care, including optimizing existing information technology, enhanced team communication and coordination, and greater continuity of care.
Sharma AE, Yang J, Del Rosario JB, et al. Jt Comm J Qual Patient Saf. 2021;47:5-14.
Ambulatory care settings are receiving increased attention as a focus for patient safety improvements. Using data from a multistate patient safety organization (PSO) database, the researchers sought to characterize patterns and characteristics of patient safety incidents reported in ambulatory care settings. Analyses found that 5.9% of events resulted in severe harm and 1.9% resulted in patient death. Over half of the events were from outpatient subspecialty care; fewer events occurred in home/community (5.2%), primary care (2.1%), or dialysis (2.0%) settings. Medication-related events were most common, followed by clinical deterioration and falls. Predictors of higher harm included diagnostic errors, patient/caregiver challenges, and events occurring in home/community or psychiatric settings. These results can help ambulatory care settings target safety events and develop systems-level prevention strategies.
Organisation for Economic Co-operation and Development.
Organizations worldwide are focusing efforts on reducing the conditions that contribute to medical error. This website provides a collection of reports and other resources that cover activities and concerns of the 37 member countries active in the organization to address universal challenges to patient safety.
Shermock KM, Streiff MB, Pinto BL, et al. J Thromb Haemost. 2011;9:1769-1775.
In this study, investigators compared international normalized ratio measurements (INR, a measurement of blood clotting ability) obtained simultaneously on a point-of-care analyzer and a standard blood draw. Although the concordance between the two measurements met traditional quality assurance standards, the point-of-care analyzer results were systematically biased toward normal measurements, putting patients at risk of preventable adverse events due to failure to adjust anticoagulant medications appropriately.
Following surgery, a woman on a patient-controlled analgesia pump is found to be lethargic and incoherent, with a low respiratory rate. The nurse contacted the attending physician, who dismisses the patient's symptoms and chastises the nurse for the late call.
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