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.
Farrell C‐JL, Giannoutsos J. Int J Lab Hematol. 2022;44:497-503.
Wrong blood in tube (WBIT) errors can result in serious diagnostic and treatment errors, but may go unrecognized by clinical staff. In this study, machine learning was used to identify potential WBIT errors which were then compared to manual review by laboratory staff. The machine learning models showed higher accuracy, sensitivity, and specificity compared to manual review.
Buitrago I, Seidl KL, Gingold DB, et al. J Healthc Qual. 2022;44:169-177.
Reducing hospital 30-day readmissions is seen as a way to improve safety and reduce costs. Baltimore City mobile integrated health and community paramedicine (MIH-CP) was designed to improve transitional care from hospital to home. After one year in operation, MIH-CP performed a chart review to determine causes of readmission among patients in the program. Root cause analysis indicated that at least one social determinant of health (e.g., health literacy) played a role in preventable readmissions; the program was modified to improve transitional care.
Holmes J, Chipman M, Barbour T, et al. Jt Comm J Qual Patient Saf. 2022;48:12-24.
Air medical transport carries unique patient safety risks. In this study, researchers used simulation training and healthcare failure mode and effect analysis (HFMEA) to identify latent safety threats related to patient transport via helicopter. This approach identified 31 latent safety threats (18 were deemed critical) related to care coordination, facilities, equipment, and devices.
Ensuring maternal safety is a patient safety priority. This library reflects a curated selection of PSNet content focused on improving maternal safety. Included resources explore strategies with the potential to improve maternal care delivery and outcomes, such as high reliability, care standardization,teamwork, unit-based safety initiatives, and...
Lurvey LD, Fassett MJ, Kanter MH. Jt Comm J Qual Patient Saf. 2021;47:288-295.
High reliability organizations encourage staff to self-report errors and hazards for comprehensive review and improvement. Three hospitals in one health system implemented a voluntary error reporting system for clinicians to report their own and others’ clinical errors. Although only 5% of reported errors were physician self-reports, there were still benefits: it captured novel errors, provided a safe space to report those errors, and encouraged secondary insights into causes of the errors.
Shaw J, Bastawrous M, Burns S, et al. J Patient Saf. 2021;17:30-35.
Patients who have fallen in their homes and are found by a home healthcare worker are referred to as “found-on-floor” incidents. This study found that length of stay was a key theme in found-on-floor incidents and signaled underlying system-level issues, such as lack of informational continuity across the continuum of care (e.g., lack of standard documentation across settings, unclear messaging regarding clients’ home care needs), reliance on home healthcare workers instead of rehabilitation professionals, and lack of fall assessment follow-up. The authors recommend systems-level changes to improve fall prevention practices, such as use of electronic health records across the continuum of care and enhanced accountability in home safety.
Ricci-Cabello I, Gangannagaripalli J, Mounce LTA, et al. J Patient Saf. 2021;17:e20-e27.
Patient safety in primary care is an emerging focus. This cross-sectional study across primary care clinics in England explored the main factors contributing to patient-reported harm experiences. Factors included incidents related to communication, care coordination, and incorrect or delayed; diagnosis and/or treatment.
Sundwall DN, Munger MA, Tak CR, et al. Health Equity. 2020;4:430-437.
This study surveyed 9,206 adults across the United States about their perceptions of medical errors occurring in ambulatory care settings. Thirty-six percent of respondents perceived that their doctor has ever made a mistake, provided an incorrect diagnosis, or given an incorrect (or delayed) treatment. According to these findings, patient-perceived medical errors and harms occurred most commonly in women and those in poor health with comorbid conditions.
Lack of timely follow-up of test results is a recognized patient safety problem in primary care and can lead to missed or delayed diagnoses. This study used human factors methods to understand lack of timely follow-up of abnormal test results in outpatient settings. Through interviews with the ordering physicians, the researchers identified several contributing factors, such as provider-patient communication channel mismatch and diffusion of responsibility.
The author defines ‘work debate spaces’ as organizational spaces that serve as a vehicle for organizational learning, practice changes, and performance improvement. This article discusses the role of formal and informal ‘work debate spaces’ in establishing a culture of safety in critical care settings. Examples of formal and informal spaces include mortality and morbidity (M&M) meetings (formal) and handoffs between shifts (informal).
Lindblad M, Unbeck M, Nilsson L, et al. BMC Health Serv Res. 2020;20:289.
This study used a trigger tool to retrospectively identify and characterize no-harm incidents affecting adult patients in home healthcare settings in Sweden. The most common incidents identified by the trigger tool were falls without injury, medication management incidents, and moderate pain. Common contributing factors included delayed, erroneous, or incomplete nursing care and treatment.
In this retrospective review of root cause analysis (RCA) reports of select gastrointestinal procedures, researchers identified 27 adverse events 30-month period. Nearly half (48%) of events caused major or catastrophic harm. The most frequently reported adverse events were attributable to human factors (22%), medication errors (22%) or retained items; retained items were associated with the most harm.
Scott J, Dawson P, Heavey E, et al. J Patient Saf. 2021;17:e1744-e1758.
This study reviewed incident reports involving older adult patient transitions in geriatrics, cardiology, orthopedics and stroke to identify the types of transitions involved and whether reports included any evidence of individual or organizational learning. Half of all incident reports involved interunit/department/team transfers and the majority (69%) of incidents were related to pressure injuries, falls, medication, and documentation errors. Few incident reports referenced individual or organizational learning (e.g., team discussions, root cause analysis) to inform practice or policy changes. A prior WebM&M describes a medication error occurring during an intrahospital transfer between the ICU and interventional radiology.
Handoffs represent a vulnerable time for patients when lapses in communication may adversely impact safety. Prior research has shown that medication errors occur frequently among patients transferred from ICU to non-ICU locations within the same hospital. In this qualitative study, physicians reviewed transfer notes and handoff documents for 50 patients transferred from a pediatric ICU to a medical unit. They found clinically relevant differences between the handoff and transfer note documentation in 42% of the transfers and conclude that such discrepancies are both common and place patient safety at risk. A previous WebM&M commentary described an adverse event related to a patient handoff.
Russo E, Sittig DF, Murphy DR, et al. Healthc (Amst). 2016;4:285-290.
Using a case study on missed and delayed follow-up of test results, this commentary explores challenges and opportunities that data from electronic health records present for patient safety research. Key barriers to utilizing electronic health record data to inform improvement work include restricted access to data, difficulty interpreting data, and workforce issues.
Rayo MF, Mount-Campbell AF, O'Brien JM, et al. BMJ Qual Saf. 2014;23:483-9.
Researchers performed direct observation of nurse and physician handoff communication to assess their use of interactive questioning, a recommended aspect of this approach. Experienced providers utilized more interactive questioning, and physicians used interactive questioning more often than nurses. These results suggest that providers acquire handoff skills over time and that such techniques may be needed in education for less experienced providers.
Bowie P, Halley L, McKay J. BMJ Open. 2014;4:e004245.
In this qualitative study, outpatient practice administrators identified weaknesses in management of patient test results: system flaws, poor communication within health care teams, challenges to informing patients of results, and difficulties associated with ensuring follow-up and confidentiality. This study underscores persisting concerns related to test results management, despite longstanding work in this area.
Chui MA, Stone JA. Res Social Adm Pharm. 2014;10:195-203.
This qualitative study used interviews with community pharmacists to characterize the types of latent errors that can contribute to problems with handoffs in care. Since the handoff process was not standardized, pharmacists reported encountering both information overload and a lack of accurate information when giving and receiving handoffs.
Kerckhoffs MC, van der Sluijs AF, Binnekade JM, et al. J Patient Saf. 2013;9.
Conceptually analogous to failure mode and effect analysis, the Bow-Tie method is used to prospectively detect safety hazards. In this study, the Bow-Tie method was used to identify latent safety hazards in intrahospital transport, risk factors for unintentional extubation, and contributors to poor interdisciplinary communication.
Smith MW, Giardina TD, Murphy DR, et al. BMJ Qual Saf. 2013;22:1006-13.
In this study, primary care providers frequently relied on extraordinary actions to overcome system barriers in obtaining their patients' timely and safe cancer evaluations. This finding provides evidence that downstream measures, such as timeliness of diagnosis, may fail to detect major system problems.
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