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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 126 Results
Rockville, MD: Agency for Healthcare Research and Quality.
In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. The 2022 report discusses a decrease in life expectancy due to the COVID-19 pandemic. It also reviews the current status of special areas of interest such as maternity care, child and adolescent mental health, and substance abuse disorders. 
Tsilimingras D, Natarajan G, Bajaj M, et al. J Patient Saf. 2022;18:462-469.
Post-discharge events, such as medication errors, can occur among pediatric patients discharged from inpatient settings to home. This prospective cohort, including infants discharged from one level 4 NICU between February 2017 and July 2019, identified a high risk for post-discharge adverse events, (including procedural complications and adverse drug events) and subsequent emergency department visits or hospital readmissions. Nearly half of these events were due to management, therapeutic, or diagnostic errors and could have been prevented.
Khan A, Parente V, Baird JD, et al. JAMA Pediatr. 2022;176:776-786.
Parent or caregiver limited English proficiency (LPE) has been associated with increased risk of their children experiencing adverse events. In this study, limited English proficiency was associated with lower odds of speaking up or asking questions when something does not appear right with their child’s care. Recommendations for improving communication with limited English proficiency patients and families are presented.
Maloney LM, Alptunaer T, Coleman G, et al. J Emerg Med. 2020;59:872-883.
Naloxone administration in inpatient and outpatient settings is used to mitigate the effects of opioid overdose. This study, conducted at one academic medical center, found that an increasing number prehospital naloxone doses for suspected opioid overdose was significantly associated with an increased likelihood of adverse events (AEs) in the emergency department (ED).
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.
Berry D, Wakefield E, Street M, et al. J Adv Nurs. 2020;76:2235-2252.
Isolation for infection prevention and control is beneficial but may result in unintended consequences for patients (e.g., less attention, suboptimal documentation and communication, higher risk of preventable adverse events). This systematic review did not identify any evidence suggesting that adult patients in isolation precautions for infection control are more likely to experience clinical deterioration or hospital-acquired complications compared to non-insolated patients.
J Patient Saf. 2020;16:s1-s56.
The patient safety evidence base has been growing exponentially for two decades with noted expansion into the non-acute care environment. This special issue highlights eight articles illustrating the range of practices examined in the AHRQ Making Healthcare Safer III report, including rapid response teams and failure to rescue, deprescribing practices and opioid stewardship.   
Chauhan A, Walton M, Manias E, et al. Int J Equity Health. 2020;19:118.
In this systematic review, the authors characterized patient safety events affecting ethnic minority populations internationally. Findings indicate that ethnic minority populations experience higher rates of hospital-acquired infections, complications, adverse drug events, and dosing errors. The authors identified several factors contributing to the increased risk, including language proficiency, beliefs about illness and treatment, interpreter use, consumer engagement, and interactions with health professionals.

Holmes A, Long A, Wyant B, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2020. AHRQ Publication No. 20-0029-EF.

This newly issued follow up to the seminal AHRQ Making Health Care Safer report (first published in 2001 and updated in 2013 critically examines the evidence supporting 47 separate patient safety practices chosen for the high-impact harms they address. It includes diagnostic errors, failure to rescue, sepsis, infections due to multi-drug resistant organisms, adverse drug events and nursing-sensitive conditions. The report discusses the evidence on cross-cutting safety practices, including safety culture, teamwork and team training, clinical decision support, patient and family engagement, cultural competency, staff education and training, and monitoring, audit and feedback. The report provides recommendations for clinicians and decision-makers on effective patient safety practices.

Halamek LP, ed. Semin Perinatol. 2019;43(8):151172-151182.
 

The neonatal intensive care unit (NICU) is a complex environment that serves a vulnerable population at increased risk for harm should errors occur. This special issue draws from a multidisciplinary set of authors to explore patient safety issues arising in the NICU. Included in the issue are articles examining topic such as video assessment, diagnostic error, and human factors engineering in the NICU.
Cullen SW, Xie M, Vermeulen JM, et al. Med Care. 2019;57:913-920.
Various factors can impact patient safety risk in psychiatric settings. This study assessed the prevalence of AEs and MEs in community hospitals and Veterans Health Administration (VHA) hospitals and found that psychiatric inpatients at community hospitals were twice as likely to experience these patient safety events than VHA inpatients, even after controlling for patient and hospital characteristics.
Maatman TC, Prigmore H, Williams JS, et al. BMJ Qual Saf. 2019;28:934-938.
This educational intervention used a comic book format to convey patient safety concepts to internal medicine residents. Awareness and confidence in patient safety topics including medication safety and fall prevention improved on the post-test compared to the pre-test, suggesting this modality has promise as a patient safety education tool.
Woeltje KF, Olenski LK, Donatelli M, et al. Joint Commission journal on quality and patient safety. 2019;45:480-486.
The Eisenberg Award honors individuals and organizations who have made important contributions to patient safety and quality improvement. Spotlighting the accomplishments of the 2018 recipients, this special issue includes an interview with Dr. Brent C. James, as well as articles on programs at The Society of Thoracic Surgeons and BJC HealthCare.
Walsh ME, Boland F, Moriarty F, et al. Drugs Aging. 2019;36:461-470.
After an older adult has a fall, medication deprescribing is a crucial intervention to prevent future harm. This study of a large sample of elderly patients in Ireland found that they were frequently prescribed medications that increased their risk of falling, and deprescribing was rare after a fall-related hospitalization. A WebM&M commentary discussed tactics to more safely manage older patients' medications.
WebM&M Case May 1, 2019
Following catheter-guided thrombolysis for a large saddle pulmonary embolism, a man was monitored in the intensive care unit. The catheters were removed the next day, and the patient was sent from the interventional radiology suite to the postanesthesia care unit, after which he was transferred to a telemetry bed on the stepdown unit. No explicit plan for anticoagulation was discussed with the accepting medical team. Shortly after the nurse found the patient lethargic, tachycardic, and hypoxic, the patient lost his pulse and a code was called.
Cheung R, Roland D, Lachman P. Arch Dis Child. 2019;104:1130-1133.
Children are vulnerable to delayed or missed diagnosis, infections, and medication errors. This commentary summarizes the current state of pediatric patient safety improvement efforts in the United Kingdom and emphasizes the importance of systems approaches to safety. The authors highlight huddles and pediatric early warning systems as two tactics that improve the reliability of communication to address the complex needs of pediatric patients.
Riskin A, Bamberger P, Erez A, et al. Jt Comm J Qual Patient Saf. 2019;45:358-367.
Prior studies have demonstrated that rude behavior undermines patient safety. This study used a smartphone application to collect reports of rudeness directed toward nurses. These data were analyzed in conjunction with the hospital's hand hygiene and medication protocol compliance data as well as adverse event reports to determine if rudeness affected these safety outcomes. Participants also reported whether rudeness incidents influenced their cognition or their teamwork. Although rudeness was associated with worse self-reported cognition and teamwork, investigators did not observe differences in reported adverse events or changes in hand hygiene or medication protocol adherence related to rudeness exposure. A past PSNet perspective discussed how organizations are seeking to rehabilitate persistently disruptive clinicians.
WebM&M Case April 1, 2019
An elderly man with a complicated medical history slipped on a rug at home, fell, and injured his hip. Emergency department evaluation and imaging revealed no head injury and a left intertrochanteric hip fracture. Although he was admitted to the orthopedic surgery service, with surgery to fix the fracture initially scheduled for the next day, the operation was delayed by 3 days due to several emergent trauma cases and lack of surgeon availability. He ultimately underwent surgery and was discharged a few days later but was readmitted several weeks later with chest pain and shortness of breath.
Brewer BB, Carley KM, Benham-Hutchins MM, et al. J Nurs Adm. 2018;48:437-444.
Researchers describe the use of a social network analysis tool to examine the impact of nursing staff information sharing and advice networks on several patient safety outcomes, including medication errors, falls, and hospital-acquired pressure ulcers, across 24 medical and surgical inpatient units at 3 hospitals. They conclude that such an approach may provide supervisors with useful information for system-level change.
Sunshine JE, Meo N, Kassebaum NJ, et al. JAMA Netw Open. 2019;2:e187041.
The seminal report, To Err Is Human, famously estimated that 44,000 to 98,000 deaths per year in the United States were due to medical errors. Although certain patient harms thought to be unavoidable at the time of the report's publication in 1999 are now considered completely preventable, experts suggest that progress in the field of patient safety has been slower than initially anticipated and that areas such as ambulatory safety and diagnostic error represent emerging priorities. In this cohort study, researchers used data from 1990 through 2016 on mortality related to the adverse effects of medical treatment (AEMT) from the Global Burden of Diseases, Injuries, and Risk Factors 2016 study. For the study period, researchers attribute 123,603 deaths to AEMT. The number of such deaths increased, but the US age-standardized mortality rate for deaths due to AEMT decreased by 21% between 1990 and 2016. The authors noted similar AEMT mortality rates for men as compared to women, significantly increased AEMT mortality rates for those age 70 and older, and geographic variation with regard to age-standardized AEMT mortality rates. An Annual Perspective discussed challenges associated with measuring and responding to deaths associated with medical errors.