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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 1682 Results

Eldeib D. ProPublica. November 13, 2022.

Pregnancy is recognized as a high-risk condition for both mother and infant. This news story examines the potential for stillbirth and its preventability. Lack of respect for the concerns of mothers, inadequate attention to research, and poor patient education are discussed as contributors to stillbirth.

Meyer DB. Boca Raton, FL: Universal Publishers; 2022. ISBN:‎ 9781627344067

Individual commitment to patient safety can motivate change. This book highlights an advocacy action by a patient safety leader to generate awareness, engagement, and action using personal, professional, and patient stories of error.
Carmack A, Valleru J, Randall KH, et al. Jt Comm J Qual Patient Saf. 2022;Epub Sep 30.
Retained surgical items (RSI) are a never event, a serious and preventable event. After experiencing a high rate of RSIs, this United States health system implemented a bundle to reduce RSI, improve near-miss reporting, and increase process reliability in operating rooms. The bundle consisted of five elements: surgical stop, surgical debrief, visual counters, imaging, and reporting.
Pun BT, Jun J, Tan A, et al. Am J Crit Care. 2022;31:443-451.
Team collaboration is an essential part of ensuring patient safety in acute care settings. This survey of care team members (including nurses, physicians, pharmacists, respiratory therapists, and rehabilitation therapists) assessed teamwork and collaboration across 68 intensive care units (ICUs). Teamwork and work environment were rated favorably but care coordination and meaningful recognition were rated least favorably.
Rosen A, Carter D, Applebaum JR, et al. J Patient Saf. 2022;18:e1219-e1225.
The COVID-19 pandemic had wide-ranging impacts on care delivery and patient safety. This study examined the relationship between critical care clinician experiences related to patient safety during the pandemic and COVID-19 caseloads during the pandemic. Findings suggest that as COVID-19 caseloads increased, clinicians were more likely to perceive care as less safe.
Auschra C, Asaad E, Sydow J, et al. J Patient Saf. 2022;18:e1211-e1218.
Health systems are increasingly aiming to become high-reliability organizations, able to operate for an extended period without serious accidents. This systematic review identified 75 studies reporting on health systems’ interventions to improve reliability, the goals of the interventions, and how achievement of the goals was measured. The six goals of Crossing the Quality Chasm were used to categorize studies. Most studies focused solely or in part on safety; only ten focused solely on one of the other five goals.
Wilson M-A, Sinno M, Hacker Teper M, et al. J Patient Saf. 2022;18:680-685.
Achieving zero preventable harm is an ongoing goal for health systems. In this study, researchers developed a five-part strategy to achieve high-reliability and eliminate preventable harm at one regional health system in Canada – (1) engage leadership, (2) develop an organization-specific patient safety framework, (3) monitor specific quality aims (e.g., high-risk, high-cost areas), (4) standardize the incident review process, including the use of root cause analysis, and (5) communicate progress to staff in real-time via electronic dashboards. One-year post-implementation, researchers observed an increase in patient safety incident reporting and improvements in safety culture, as well as decreases in adverse events such as falls, pressure injuries and healthcare-acquired infections.
Starmer AJ, Spector ND, O'Toole JK, et al. J Hosp Med. 2022;Epub Nov 3.
I-PASS is a structured handoff tool to enhance communication during patient transfers and improve patient safety. This study found that I-PASS implementation at 32 hospitals decreased major and minor handoff-related adverse events and improved key handoff elements (e.g., frequency of handoffs with high verbal quality) across provider types and settings.
WebM&M Case November 16, 2022

A 58-year-old man underwent a complex surgery to replace his aortic valve. The surgery required prolonged cardiopulmonary bypass time and cross-clamp time and there was a short delay in redosing the cardioplegic solution and the patient developed “stone heart” due to suspected ischemic injury and was unable to come off bypass. The patient was placed on extracorporeal membrane oxygenation (ECMO) and transported to the ICU to allow family members to see the patient before stopping life support.

WebM&M Case November 16, 2022

A 61-year-old women with a mechanical aortic valve on chronic warfarin therapy was referred to the emergency department (ED) for urgent computed tomography (CT) imaging of the right leg to rule out an arterial clot. CT imaging revealed two arterial thromboses the right lower extremity and an echocardiogram revealed a thrombus near the prosthetic heart valve. The attending physician ordered discontinuation of warfarin and initiation of a heparin drip.

Patient Safety Innovation November 16, 2022

While electronic health records, computerized provider order entry, and clinical decision support have increased patient safety, they can also create new challenges such as alert fatigue. One medical center developed and implemented a program to identify and reduce the number of alerts clinicians encounter every day. 

Patient Safety Innovation November 16, 2022

Appropriate follow-up of incidental abnormal radiological findings is an ongoing patient safety challenge. Inadequate follow-up can contribute to missed or delayed diagnosis, potentially resulting in poorer patient outcomes. This study describes implementation of an electronic health record-based referral system for patients with incidental radiologic finding in the emergency room. 

Jean-Pierre P. Boston U Law Rev. 2022; 102(1):327-392.

Bias and discrimination are receiving overdue attention as primary barriers to patient safety. This article discusses medical error, ineffective response to error, social trust and health care, state apology laws and the role of communication and resolution programs (CRP) to reduce additional harms associated with medical errors, all in the context of marginalized populations.
Okoli J, Arroteia NP, Ogunsade AI. Leadersh Health Serv (Bradf Engl). 2022;Epub Sep 22.
At the start of the COVID-19 pandemic, leaders around the world were forced to rapidly made decisions with limited knowledge of the impact those decisions would have on public health. This review of research, policy and the media highlights three cognitive antecedents to crisis leadership failures: 1) ignoring the precautionary principle (e.g., “better safe than sorry”), 2) the illusion of control, and 3) poor uncertainty management tactics. Recommendations for future successful crisis leadership include avoiding optimistic bias, avoiding conflicting information, and frame and communicate risk messages in the right way.
Welch-Horan TB, Mullan PC, Momin Z, et al. Adv Simul (Lond). 2022;7:36.
The COVID-19 pandemic challenged the way healthcare teams functions. This article describes the implementation of a hospital-wide COVID-19 clinical event debriefing program, which encouraged care team members to reflect on what went well and what could be improved upon during care encounters with patients hospitalized with COVID-19. Qualitative synthesis of 31 debriefings highlighted issues with personal protective equipment, confusion around team roles, and the importance of both intra-team communication and situational awareness.

Washington, DC: Veterans Affairs Office of Inspector General; 2022. Report No. 22-00818-03.

Organizational evaluations often reveal opportunities to address persistent quality and safety issues. This extensive inspection report shares findings from examinations at 45 Veterans Health Administration care facilities that focused on assessing oversight, system redesign and surgical programs. Recommendations drawn from the analysis call for improvements in protected peer review, surgical work structure and surgical adverse incident examination.
Turner A, Morris R, McDonagh L, et al. Br J Gen Pract. 2022;Epub Sep 5.
Patient access to electronic health records can improve engagement in care. This qualitative study involving patients and staff at general practices in the United Kingdom highlighted unintended consequences of online access to health records, including challenges with patient health literacy, decreased quality of documentation, and increases in staff workload.

Plymouth Meeting, PA: ECRI and the Institute for Safe Medication Practices; 2022.

Racist behavior directed at either patients or clinicians can degrade the safety of care. This report reviewed over 500 race- or ethnicity-related patient safety incidents to determine the types of actions involved and the role of the individual committing the action. In addition, the impact of the behaviors on the mental health of providers is examined. The report suggests strategies for understanding, detecting, and reducing health disparities.