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 462 Results

Incidence and characteristics of adverse events in paediatric inpatient care: a systematic review and meta-analysis.

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Dillner P, Eggenschwiler LC, Rutjes AWS, et al. BMJ Qual Saf. 2022;Epub Dec 26.

Retrospective error detection methods, such as trigger tools, are widely used to uncover the incidence and characteristics of adverse events (AE) in hospitalized children. This review sought AEs identified by three trigger tools: Global Trigger Tool (GTT), the Trigger Tool (TT) or the Harvard Medical Practice Study (HMPS) method. Results from the trigger tools were widely variable, similar to an earlier review in adult acute care, and suggest the need for strengthening reporting standards.

Short- and long-term effects of an electronic medication management system on paediatric prescribing errors.

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Westbrook JI, Li L, Raban MZ, et al. NPJ Digit Med. 2022;5:179.

Pediatric patients are particularly vulnerable to medication errors. This cluster randomized controlled trial examined the short- and long-term impacts of an electronic medication management (eMM) system implemented at one pediatric referral hospital in Australia. Findings suggest that eMM implementation did not reduce medication errors in the first 70 days of use, but researchers observed a decrease in medication errors one year after implementation, suggesting long-term benefits.

Team debriefing in the COVID-19 pandemic: a qualitative study of a hospital-wide clinical event debriefing program and a novel qualitative model to analyze debriefing content.

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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.

The Stoplight Mobility Alert System for safety and prevention of falls in children with physical and cognitive impairments.

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Patient Safety Innovation November 16, 2022

Patient falls are a never event and a frequent focus of patient safety and quality improvement projects. This pediatric ICU implemented a colored alert system based on fall risk assessments for all admitted patients.

Measuring psychological safety and local learning to enable high reliability organisational change.

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Cartland J, Green M, Kamm D, et al. BMJ Open Qual. 2022;11:e001757.

Psychological safety is a cornerstone of high reliability organizations (HROs). This children’s hospital developed two scales (trust in team members and trust in leadership) and one composite measure (local learning) to measure staff psychological safety and evaluate the effectiveness of their transition to high reliability. More than 4,500 health system staff completed the survey; results indicate the two scales are strongly associated with the composite measure.

Implementation and facilitation of post-resuscitation debriefing: a comparative crossover study of two post-resuscitation debriefing frameworks.

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Kam AJ, Gonsalves CL, Nordlund SV, et al. BMC Emerg Med. 2022;22:152.

Debriefing after significant clinical events facilitates team-based communication, learning, and support. This study compared two post-resuscitation debriefing tools (Debriefing In Situ Conversation after Emergent Resuscitation Now [DISCERN] and Post-Code Pause [PCP]) following any intubation, resuscitation, or serious/unanticipated patient outcome in a children’s hospital. PCP was found to provide more emotional support and clinical learning, but there were no differences in the remaining categories.

Quality and Safety.

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Iyer R, Walker A, eds. Paediatr Anaesth. 2022;32(11):1176-1272.

Progress made in the adoption of infrastructure, Safety I, and Safety II concepts in high- and middle- to lower-income countries around the world support safe pediatric anesthesia care. The articles in this issue illustrate progress made over time in the specialty, highlight areas of focused attention, and examine quality improvement and Lean approaches as success strategies.

Delayed diagnosis of serious paediatric conditions in 13 regional emergency departments.

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Michelson KA, McGarghan FLE, Patterson EE, et al. BMJ Qual Saf. 2022;Epub Sep 30.

Adverse events in pediatric emergency departments (ED) are rare, but largely preventable. This study examined characteristics and risk factors of patients with delayed diagnosis (i.e., presented to the ED within one week of a previous visit) and patients without delayed diagnosis of one of 7 serious medical conditions. Patients who were Hispanic or non-Hispanic Black, had public or other insurance, or non-English speaking were associated with delayed diagnosis.

Improving discharge safety in a pediatric emergency department.

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Paydar-Darian N, Stack AM, Volpe D, et al. Pediatrics. 2022;150:e2021054307.

Errors during the discharge process can lead to return visits and adverse health outcomes. This article describes the implementation of a new standardized discharge process (including a new checklist, provider huddle, and scripted caregiver education) at one children’s hospital. Over a 19-month period, implementation of the revised discharge process led to the elimination of preventable, discharge-related serious safety events and did not result in increased length-of-stay or return visits.

Resident and nurse perspectives on the use of secure text messaging systems.

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Aziz S, Barber J, Singh A, et al. J Hosp Med. 2022;17:880-887.

The introduction of new technology can have mixed consequences on staff workflows and patient safety. Focus groups of residents and nurses in a California children’s hospital sought to assess the advantages and shortcomings of secure text messaging systems (STMS) on teamwork, patient safety, and clinician well-being. Guidelines to reduce drawbacks are described.

Standardization of pediatric noncardiac operating room to intensive care unit handoffs improves communication and patient care.

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Hebballi NB, Gupta VS, Sheppard K, et al. J Patient Saf. 2022;18:e1021-e1026.

Handoffs from one care team to another present significant risks to the patient if essential patient information is not shared or understood by all team members. Stakeholders at this children’s hospital developed a structured tool for handoff between surgery and pediatric or neonatal intensive care units. Transfer of information and select patient outcomes improved, handoff time was unchanged, and attendance by all team members increased.

To err is human, but what happens when surgeons err?

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Lin JS, Olutoye OO, Samora JB. J Pediatr Surg. 2022;Epub Jul 6.

Clinicians involved in adverse events may experience feelings of guilt, shame, and inadequacy; this is referred to as “second victim” phenomenon. In this study of pediatric surgeons and surgical trainees, 84% experienced a poor patient outcome. Responses to the adverse event varied by level of experience (e.g., resident, attending), gender, and age.

'We had such trust, we feel such fools’: how shocking hospital mistakes led to our daughter’s death.

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Mills M. The Guardian. September 3, 2022

Families experiencing medical error can harbor frustration with the system but also with themselves for allowing care mistakes to take their loved one. This first-person account shares the story of a mother’s loss of a daughter to sepsis. The memoir illustrates how lack of respect for a family’s concern contributed to the incident.

Addressing adultification of black pediatric patients in the emergency department: a framework to decrease disparities.

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Koch A, Kozhumam A. Health Promot Pract. 2022;23:555-559.

Racial biases have been uncovered in pediatric emergency care; for example, Black children are less likely to receive pain medication for appendicitis. This article describes the use of the Racism as Root Cause (RRC) framework to identify and reduce adultification (when children are perceived or treated as being older than they are) of Black children in emergency departments. RRC calls for systemic, rather than individual, efforts.

Miscommunication During the Interhospital Transport of a Critically Ill Child

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WebM&M Case August 31, 2022

A 2-year-old girl presented to her pediatrician with a cough, runny nose, low grade fever and fatigue; a nasal swab for SARS-CoV-2 and influenza was negative and lung sounds were clear. The patient developed a fever and labored breathing and was taken to the Emergency Department (ED) before being admitted to the hospital. She developed respiratory distress and clinically worsened over time until she developed respiratory failure requiring air transportation to the pediatric intensive care unit at a children’s hospital.

Trial and error: learning from malpractice claims in childhood surgery.

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Prieto JM, Falcone B, Greenberg P, et al. J Surg Res. 2022;279:84-88.

Hospitalized children are vulnerable to patient safety risks. Using a large malpractice claims database, researchers found that a wide range of pediatric surgical specialties – including orthopedics, general surgery, and otolaryngology – are most frequently associated with malpractice lawsuits. The study identified several potentially modifiable factors (i.e., patient evaluations, technical performance, and communication) that can lead to improvements in pediatric surgical safety.

Association between hospital acquired harm outcomes and membership in a national patient safety collaborative.

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Coffey M, Marino M, Lyren A, et al. JAMA Pediatr. 2022;176:924-932.

The Partnership for Patients (P4P) program launched hospital engagement networks (HEN) in 2011 to reduce hospital-acquired harms. This study reports on the outcomes of eight conditions from one HEN, Children's Hospitals' Solutions for Patient Safety (SPS). While the results do show a reduction in harms, the authors state earlier claims of improvement may have been overstated due to failure to not adjust for secular improvements. The co-director of Partnership for Patients, Dr. Paul McGann, was interviewed in 2016 for a PSNet perspective.

Body mass index category and adverse events in hospitalized children.

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Halvorson EE, Thurtle DP, Easter A, et al. Acad Pediatr. 2022;22:747-753.

Previous research has identified an association between patient weight and certain adverse events and patient safety threats, such as medication dosing errors and airway management. After analyzing data for pediatric patients discharged from a single children’s hospital, researchers in this study did not identify an association between patient body mass index (BMI) and the rate, severity, or preventability of adverse events.

Pediatric surgical errors: a systematic scoping review.

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Marsh KM, Fleming MA, Turrentine FE, et al. J Pediatr Surg. 2022;57:616-621.

Patient safety improvement can be hindered by lack of effective measurement tools. This scoping review explored how medical errors are defined and measured in studies of pediatric surgery patients. The authors identified several evidence gaps, including absence of standardized error definitions.

Family safety reporting in hospitalized children with medical complexity.

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Mercer AN, Mauskar S, Baird JD, et al. Pediatrics. 2022;150:e2021055098.

Children with serious medical conditions are vulnerable to medical errors. This prospective study examined safety reporting behaviors among parents of children with medical complexity and hospital staff caring for these patients in one tertiary children’s hospital. Findings indicate that parents frequently identify medical errors or quality issues, despite not being routinely advised on how to report safety concerns.

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