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.
Wang L, Goh KH, Yeow A, et al. J Med Internet Res. 2022;24:e23355.
Alert fatigue is an increasingly recognized patient safety concern. This retrospective study examined the association between habit and dismissal of indwelling catheter alerts among physicians at one hospital in Singapore. Findings indicate that physicians dismissed 92% of all alerts and that 73% of alerts were dismissed in 3 seconds or less. The study also concluded that a physician’s prior dismissal of alerts increases the likelihood of dismissing future alerts (habitual dismissal), raising concerns that physicians may be missing important alerts.
Kwok Y-ting, Lam M-sang. BMJ Open Qual. 2022;11:e001696.
Changes in healthcare delivery and care processes as a result of the COVID-19 pandemic have increased the risk for falls. This study explored the impact of the COVID-19 pandemic and the implementation of a fall prevention program (focused on human factors and ergonomics principles) on inpatient fall rates at one hospital in Hong Kong. Findings indicate that fall rates significantly increased from pre-COVID to during the first wave of the pandemic (July-June 2020). The fall prevention program – implemented in July 2020 – led to a reduction of fall rates, but not to pre-pandemic levels.
Aljuaid J, Al-Moteri M. J Emerg Nurs. 2022;48:189-201.
Situational awareness is the degree to which perception of a situation matches reality, and the lack of situational awareness can result in decreased patient outcomes. This study measured nurses’ situational awareness immediately after inspection of a resuscitation cart. Importantly, researchers observed significant issues related to readiness preparedness, such as empty oxygen tanks, drained batteries, and equipment failures.
Branch F, Santana I, Hegdé J. Diagnostics (Basel). 2022;12:105.
Anchoring bias is relying on initial diagnostic impression despite subsequent information to the contrary. In this study, radiologists were asked to read a mammogram and were told a random number which researchers claimed was the probability the mammogram was positive for breast cancer. Radiologists' estimation of breast cancer reflected the random number they were given prior to viewing the image; however, when they were not given a prior estimation, radiologists were highly accurate in diagnosing breast cancer.
Etheridge JC, Moyal-Smith R, Sonnay Y, et al. Int J Surg. 2022;98:106210.
Non-technical skills such as communication, teamwork, decision-making, and situational awareness are responsible for a significant proportion of surgical errors. The COVID-19 pandemic increased the stress in the operating room, associated with increased risk of exposure and shortage of resources. This study compared pre- and post-COVID direct observations during live operations and found that non-technical skills were equivalent; there was a small, but statistically significant, improvement in teamwork and cooperation skills.
Missed or incomplete nursing care can adversely affect care quality and safety. Based on survey responses from 295 frontline nurses in the Philippines, this study explored factors contributing to missed nursing care during the COVID-19 pandemic. Findings suggest that nurses most frequently missed tasks such as patient surveillance, comforting patients, skin care, ambulation, and oral hygiene. The authors suggest that increasing nurse staffing, adequate use of personal protective equipment, and improved safety culture may reduce instances of missed care.
Murata M, Nakagawa N, Kawasaki T, et al. Am J Emerg Med. 2022;52:13-19.
Transporting critically ill patients within a hospital (e.g., to radiology for diagnostic procedures) is necessary but also poses safety threats. The authors conducted a systematic review and meta-analysis of all types of adverse events, critical or life-threatening adverse events, and death occurring during intra-hospital transport. Results indicate that adverse events can occur in intra-hospital transport, and that frequency of critical adverse events and death are low.
A systems approach provides a framework to analyze errors and improve safety. This study uses the Systems Theoretic Process Analysis (STPA) to analyze risks related to pediatric sepsis treatment process. Fifty-four safety recommendations were identified, the majority of which were organizational factors (e.g., communication, organizational culture).
Pilosof NP, Barrett M, Oborn E, et al. Int J Environ Res Public Health. 2021;18:8391.
The COVID-19 pandemic has led to dramatic changes in healthcare delivery. Based on semi-structured interviews and direct observations, researchers evaluated the impact of a new model of remote inpatient care using telemedicine technologies in response to the pandemic. Intensive care and internal medicine units were divided into contaminated and clean zones and an integrated control room with audio-visual technologies allowed for remote supervision, communication, and support. The authors conclude that this model can increase flexibility in staffing via remote consultations and allow staff to supervise and monitor more patients without compromising patient and staff safety.
Bulliard J‐L, Beau A‐B, Njor S, et al. Int J Cancer. 2021;149:846-853.
Overdiagnosis of breast cancer and the resulting overtreatment can cause physical, emotional, and financial harm to patients. Analysis of observational data and modelling indicates overdiagnosis accounts for less than 10% of invasive breast cancer in patients aged 50-69. Understanding rates of overdiagnosis can assist in ascertaining the net benefit of breast cancer screening.
Linguistic, culture, and health literacy barriers between patients and providers can lead to adverse events. In addition to the use of professional interpreters, the authors suggest additional culturally and linguistically appropriate services (CLAS) to improve communication between patients, particularly refugees and migrants, and providers.
Jaam M, Naseralallah LM, Hussain TA, et al. PLoS One. 2021;16:e0253588.
Including pharmacists can improve patient safety across the medication prescribing continuum. This review identified twelve pharmacist-led educational interventions aimed at improving medication safety. The phase, educational strategy, patient population, and audience varied across studies; however most showed some reductions in medication errors.
Chang T-P, Bery AK, Wang Z, et al. Diagnosis (Berl). 2022;9:96-106.
A missed or delayed diagnosis of stroke increases the risk of permanent disability or death. This retrospective study compared rates of misdiagnosed stroke in patients presenting to general care or specialty care who were initially diagnosed with “benign dizziness”. Patients with dizziness who presented to general care were more likely to be misdiagnosed than those presenting to specialty care. Interventions to improve stroke diagnosis in emergency departments may also be successful in general care clinics.
Amit Aharon A, Fariba M, Shoshana F, et al. J Clin Nurs. 2021;30:3290-3300.
Patient suicide attempts or completions can have negative psychological impacts on the nurses involved. This mixed-methods study found a significant association between emotional distress and feeling alone with absenteeism and higher staff turnover. Healthcare organizations should develop support programs for second victims to increase resiliency and potentially decrease absenteeism and turnover.
Shao Q, Wang Y, Hou K, et al. J Adv Nurs. 2021;77:4005-4016.
Patient suicide in all settings is considered a never event. Nurses caring for the patient may experience negative psychological symptoms following inpatient suicide. This review identified five themes based on nurses’ psychological experiences: emotional experience, cognitive experience, coping strategies, self-reflection, and impact on self and practice. Hospital administrators should develop education and support programs to help nurses cope in the aftermath of inpatient suicide.
Kakemam E, Chegini Z, Rouhi A, et al. J Nurs Manag. 2021;29:1974-1982.
Clinician burnout, characterized by emotional exhaustion, depersonalization, and decreased sense of accomplishment, can result in worse patient safety outcomes. This study explores the association of nurse burnout and self-reported occurrence of adverse events during COVID-19. Results indicate higher levels of nurse burnout were correlated with increased perception of adverse events, such as patient and family verbal abuse, medication errors, and patient and family complaints. Recommendations for decreasing burnout include access to psychosocial support and human factors approaches.
Li Q, Hu P, Kang H, et al. J Nutr Health Aging. 2020;25:492-500.
Missed and delayed diagnosis are a known cause of preventable adverse events. In this cohort of 107 patients with severe or critical COVID-19 in Wuhan, China, 45% developed acute kidney injury (AKI). However, nearly half of those patients (46%) were not diagnosed during their stay in the hospital. Patients with undiagnosed AKI experienced greater hospital mortality than those without AKI or diagnosed AKI. Involvement of intensive care kidney specialists is recommended to increase diagnostic awareness.
Panda N, Sinyard RD, Henrich N, et al. J Patient Saf. 2021;17:256-263.
The COVID-19 pandemic has presented numerous challenges for the healthcare workforce, including redeploying personnel to different locations or retraining personnel for different tasks. Researchers interviewed hospital leaders from health systems in the United States, United Kingdom, New Zealand, Singapore and South Korea about redeployment of health care workers during the COVID-19 pandemic. The authors discuss effective practices and lessons learned preparing for and executing workforce redeployment, as well as concerns regarding redeployed personnel
Denning M, Goh ET, Tan B, et al. PLoS One. 2021;16:e0238666.
This cross-sectional study conducted from March to June 2020 measured anxiety, depression, and burnout in clinicians working in the United Kingdom, Poland, and Singapore. Approximately 70% of respondents reported feeling anxious, depressed and/or burnt out. Burnout was significantly inversely correlated with being tested for COVID-19 and perceiving high levels of safety. These findings highlight the importance of supporting staff well-being and proactive COVID-19 testing.
The relationship between resident and physician duty hours and patient safety has been the focus of a lot of research. The relationship between nurse work schedules and patient safety is less explored. This review investigated the effect of extended or excessive nurse schedules on patient outcomes. Findings conclude that working more than 12 hours daily or more than 40 hours weekly may contribute to adverse patient outcomes. The authors recommend creating policies restricting nurse shifts to no more than 12 hours per day and 40 hours per week.
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