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.
De Cassai A, Negro S, Geraldini F, et al. PLoS One. 2021;16:e0257508.
Inattentional blindness occurs when individuals miss an unexpected event due to competing attentional tasks. This study asked anesthesiologists to review the anesthetic management of five simulated cases, one of which included the image of a gorilla in the radiograph, to evaluate inattentional blindness. Only 4.9% of social media respondents reported an abnormality, suggesting that inattentional blindness may be common; the authors suggest several strategies to reduce this error.
McHale S, Marufu TC, Manning JC, et al. Nurs Crit Care. 2021;Epub Oct 20.
Failure to identify and prevent clinical deterioration can reflect the quality and effectiveness of care. This study used routinely collected emergency event data to identify failure to rescue events at one tertiary children’s hospital. Over a nine-year period, 520 emergency events were identified; 25% were cardiac arrest events and 60% occurred among patients who had been admitted for more than 48 hours. Over the nine-year period, failure to rescue events decreased from 23.6% to 2.5%.
Walton E, Charles M, Morrish W, et al. J Patient Saf. 2022;18:e620-e625.
Dialysis is a common procedure that carries risks if not performed correctly. This study analyzed dialysis-related bleeding events reported to the Veterans Health Administration Patient Safety Authority over an 18-year period. The analysis identified four areas of focus to reduce bleeding events – (1) the physical location and equipment used, (2) staff commitment to standardization and attention to detail (to reduce unwitnessed bleeding events), (3) mental status of the patient, and (4) the method for hemodialysis delivery.
Bekes JL, Sackash CR, Voss AL, et al. AANA J. 2021;89(4):319-324.
Pediatric medication errors during anesthesia can lead to significant harm and are largely preventable. This review identifies several themes around medication errors including dosing and incorrect medication. Successful error reduction strategies, such as standardized labeling and pre-filled syringes, are also described.
Bennion J, Mansell SK. Br J Hosp Med (Lond). 2021;82:1-8.
Many strategies have been developed to improve recognition of, and response, to clinically deteriorating patients. This review found that simulation-based educational strategies was the most effective educational method for training staff to recognize unwell patients. However, the quality of evidence was low and additional research into simulation-based education is needed.
Flowerdew L, Tipping M. Emerg Med J. 2021;38:769-775.
This study sought to validate an emergency department (ED) safety questionnaire developed in the United States, and adapted for use in the UK. The survey was validated by 33 patient safety leads and used in a multi-center survey. Analysis highlighted risks and positive factors (e.g., positive safety culture) present in surveyed EDs.
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.
Halsey-Nichols M, McCoin N. Emerg Med Clin North Am. 2021;39:703-717.
Diagnostic errors among patients presenting to the emergency department (ED) with abdominal pain are common. This article summarizes the factors associated with missed diagnoses of abdominal pain in the ED, the types of abdominal pain that are commonly misdiagnosed, and recommended steps for discharging a patient with abdominal pain without a final diagnosis.
Härkänen M, Haatainen K, Vehviläinen-Julkunen K, et al. Int J Environ Res Public Health. 2021;18:9206.
Building on previous research on the use of text mining related to medication administration error incidents, researchers in this study found that artificial intelligence can be used to accurately classify the free text of medication incident reports causing serious or moderate harm, to identify target risk management areas.
Heitkamp A, Meulenbroek A, van Roosmalen J, et al. Bull World Health Organ. 2021;99:693-707F.
Maternal safety is a patient safety priority. According to this systematic review including 69 studies, the maternal near miss incidence rate is estimated to be 15.9 cases per 1,000 live births in lower-middle income countries and 7.8 cases per 1,000 live births in upper-middle-income countries. The most common causes of near miss were obstetric hemorrhage and hypertensive disorders.
Klasen JM, Teunissen PW, Driessen EW, et al. Med Teach. 2022;44:196-205.
Previous research has found that error permission (allowing errors to arise naturally and not preventing them) is a common strategy used in clinical training. This qualitative study with supervising physicians found that decisions to allow residents to fail are often made in the moment and are influenced by the patient, supervisor, trainee, and environmental factors.
Sharma AE, Huang B, Del Rosario JB, et al. BMJ Open Qual. 2021;10:e001421.
Patients and caregivers play an essential role in safe ambulatory care. This mixed-methods analysis of ambulatory safety reports identified three themes related to patient and caregivers factors contributing to events – (1) clinical advice conflicting with patient priorities, (2) breakdowns in communication and patient education contributing to medication adverse events, and (3) the fact that patients with disabilities are vulnerable to due to the external environment.
Simpson M, Kovach CR. Res Gerontol Nurs. 2021;14:293-304.
This prospective study explored iatrogenic events emerging among older adults in one post-acute care hospital. Researchers found that most new problems were exacerbations of preexisting conditions rather than problems stemming from the primary reason for hospitalization. Findings indicate risk factors such as comorbidities or functional level may not be useful in determining the likelihood of new problems or iatrogenic events during post-acute rehabilitation.
Sotto KT, Burian BK, Brindle ME. J Am Coll Surg. 2021;233:794-809.e8.
The World Health Organization (WHO) Surgical Safety Checklist has been implemented in healthcare systems around the world. This systematic review and thematic analysis concluded that the surgical safety checklist positively impacts clinical outcomes (surgical outcomes and mortality), process measures, team dynamics, and communication, as well as safety culture. The authors note that the checklist was negatively associated with efficiency and workload; included studies often noted that checklist users felt the checklist slowed down processes within the operating room
Moy E, Hausmann LRM, Clancy CM. Am J Med Qual. 2022;37:81-83.
Shortcomings in health equity represent systemic weaknesses in health care. This commentary suggests that actions to reduce disparities be added to the components of high reliability organizations (HRO) to facilitate an expansion of the HRO concept to address the threat to patient safety that inequity represents.
Chaker A, Omair I, Mohamed WH, et al. Am J Health Syst Pharm. 2022;79:187–192.
The Institute for Safe Medication Practices recommends compounding pharmacies use technology and automation to improve patient safety. Researchers assessed the workflow and workforce requirements of one hospital’s sterile preparation center (SPC) following implementation of these recommendations. The average time to prepare each type of medication was used to determine pharmacy staffing workforce requirements.
Freeman K, Geppert J, Stinton C, et al. BMJ. 2021;374:n1872.
Artificial intelligence (AI) has been used and studied in multiple healthcare processes, including detecting patient deterioration and surgical decision making. This literature review focuses on studies using AI to detect breast cancer in mammography screening practice. The authors recommend additional prospective studies before using artificial intelligence in clinical practice.
O’Connor P, O’Malley R, Lambe KA, et al. Int J Qual Health Care. 2021;33:mzab138.
Patient safety incidents occurring in prehospital care settings are gaining increasing attention. This systematic review including both peer-reviewed studies and grey literature found that the incidence rate of prehospital patient safety incidents is similar to hospital rates. The authors identified an average of 5.9 patient safety incidents per 100 records/transports/patients occurring in prehospital care; approximately 15% of these incidents resulted in patient harm. The authors discuss methodological challenges to preshopital care research and make recommendations for future studies.
Townsend T, Cerdá M, Bohnert AS, et al. Health Aff (Millwood). 2021;40:1766-1775.
Misuse of prescription opioids represents a serious patient safety issue. Using commercial claims from 2014 - 2018, researchers examined the association between the 2016 CDC guidelines to reduce unsafe opioid prescribing and opioid dispensing for patients with four common chronic pain diagnoses. Findings indicate that the release of the 2016 guidelines was associated with reductions in the percentage of patients receiving opioids, average dose prescribed, percentage receiving high-dose prescriptions, number of days supplied, and the percentage of patients receiving concurrent opioid/benzodiazepine prescriptions. The authors observe that questions remain about how clinicians are tailoring opioid reductions using a patient-centered approach.
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.
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