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.
Uramatsu M, Maeda H, Mishima S, et al. J Cardiothorac Surg. 2022;17:182.
Wrong-patient transfusion errors can lead to serious patient harm. This case report describes a blood transfusion error and summarizes the systems issues that emerged during the root case analysis, as well as the corrective steps implemented by the hospital to prevent future transfusion errors. A previous Spotlight Case featured a near-miss transfusion error and strategies for ensuring safe transfusion practices.
Strong patient safety culture is a cornerstone to sustained safety improvements. This cross-sectional study explored nurses’ perceptions about patient safety culture. Identified areas of strength included non-punitive responses to errors and teamwork, and areas for improvement focused on supervisor and manager expectations, responses, and actions to promote safety and open communication. The authors highlight the importance of measuring patient safety culture in order to improve hospitals’ patient safety improvement practices, overall performance and quality of healthcare delivery.
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).
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.
Denning M, Goh ET, Scott A, et al. Int J Environ Res Public Health. 2020;17:7034.
This study used the Safety Attitudes Questionnaire to evaluate the impact of COVID-19 on safety culture at a large UK teaching hospital compared to baseline scores collected in 2017. Overall, respondents reported more positive perceptions of safety; training and support for redeployment were associated with higher perceptions of safety. However, the analysis identified a significant decrease in error reporting after the onset of the COVID-19 pandemic.
Sim MA, Ti LK, Mujumdar S, et al. J Patient Saf. 2022;18:e189-e195.
This article describes the implementation of a hospital-wide patient safety strategy aimed at reducing hospital-wide adverse events at a single large hospital in Singapore. The strategy included establishing interdisciplinary patient safety teams to identify areas of preventable harm, determine root causes, improve departmental accountability, and leveraging simulation training. Over a 7-year period, adverse event rates decreased significantly (as did the incidence of preventable adverse events and the incidence of events resulting in permanent harm, the use of life-sustaining interventions, or death.
Fahrni ML, Azmy MT, Usir E, et al. PLoS One. 2019;14:e0219898.
In this prospective study involving 301 older patients admitted to 3 hospitals, researchers used the STOPP and START criteria to identify inappropriate prescribing and adverse drug events. Inappropriate prescribing was detected in 59% of patients and potentially inappropriate medications in 35% of patients. The use of inappropriate medications was associated with an increased odds of an adverse drug event.
Abe T, Tokuda Y, Shiraishi A, et al. Crit Care. 2019;23:202.
This retrospective study sought to determine whether timely diagnosis of the site of infection affected in-hospital mortality for sepsis. Investigators found that patients whose infection site was misdiagnosed on admission had more than twofold greater odds of dying in the hospital compared to those with the correct infection site diagnosed on admission. These results reinforce the importance of correct and timely diagnosis for sepsis outcomes.
Chui MA, Pohjanoksa-Mäntylä M, Snyder ME, eds. Res Social Adm Pharm. 2019;15(7):811-906.
Medication safety is a worldwide challenge. This special issue discusses factors affecting the reliability of the ordering, dispensing, and administration of medications across a range of environments. Articles cover topics such as the need to deepen understanding of safety in community pharmacies, the use of smart pumps for high-alert medications, and the international effort to reduce medication-related harm.
Halperin O, Bronshtein O. Nurse Educ Pract. 2019;36:34-39.
Underreporting of safety events and near misses in the health care setting has been well described and is one of the challenges in using data from incident reporting systems to measure safety. Researchers surveyed nursing students and clinical instructors to identify barriers to reporting and found that fear of negative consequences was a major factor.
Ericsson C, Skagerström J, Schildmeijer K, et al. BMJ Qual Saf. 2019;28:657-666.
Patient engagement in safety is considered a best practice and a National Patient Safety Goal, but less is known about patients' perceptions regarding this topic. In this survey study involving 1445 patients in Sweden, researchers found that more than 80% of respondents felt comfortable directing questions to doctors and nurses. Patients who had filed a formal complaint reporting a safety concern were found to believe with greater certainty that the patient perspective can improve the safety of care.
Lee W-H, Zhang E, Chiang C-Y, et al. J Patient Saf. 2019;15:61-68.
Trigger tools and incident reporting are widely utilized methods for detecting harm in health care. The most useful method for capturing safety events in the emergency department remains unknown. In this prospective observational study, researchers assessed a monitoring system designed to detect adverse events in the emergency department of an academic medical center over a 1-year period. The system included two event reporting methods and five trigger tools. Of the 285 adverse events identified during the study period, 77.2% were captured by reporting systems, 26% by trigger tools, and 3.2% by both approaches. In keeping with prior research, the authors conclude that the use of a combination of methods for capturing harm is more effective than the use of a singular approach. A past PSNet perspective highlighted the importance of feedback with regard to incident reporting.
George D, Hassali MA, Hss A-S. JMIR Hum Factors. 2018;5:e12232.
This mixed-methods study examined the usability of a mobile application for reporting medication errors at a referral hospital in Malaysia. Usability improved over each of the three cycles of testing and iterative redesign, but physician and nurse testers expressed concern about whether the safety culture supported reporting.
Mongkhon P, Ashcroft DM, Scholfield N, et al. BMJ Qual Saf. 2018;27:902-914.
This meta-analysis sought to identify the prevalence of hospital admissions attributed to nonadherence to medications. There was significant heterogeneity among the included studies. Researchers found that about 1% to 10% of hospital admissions are due to nonadherence to medications in the outpatient setting and are therefore preventable.
Liu D, Gan R, Zhang W, et al. J Clin Pathol. 2018;71:67-71.
Autopsies are an underutilized tool for identifying diagnostic errors. Researchers evaluated 117 autopsies for patients in Shanghai whose cause of death was disputed or required third-party investigation. Diagnostic errors that would have altered treatment or survival were found in nearly 61%. This number is higher than estimates from a previous systematic review, likely because all patients in this sample had a disputed cause of death.
Westbrook JI, Raban MZ, Walter SR, et al. BMJ Qual Saf. 2018;27:655-663.
This direct observation study of emergency physicians found that interruptions, multitasking, and poor sleep were associated with making more medication prescribing errors. These results add to the evidence that clinical environments prone to interruptions may pose a safety risk.
Mekory TM, Bahat H, Bar-Oz B, et al. Int J Qual Health Care. 2017;29:366-370.
Research has shown that Joint Commission accreditation is associated with higher quality care. In this retrospective study, investigators compared prescribing errors and medication administration errors among pediatric ward patients and pediatric emergency department patients before and during implementation of the Joint Commission International accreditation program. Although they found a significant reduction in prescribing errors, medication administration errors did not decrease.
Lee J, Park SW, Kim YS, et al. Medicine (Baltimore). 2017;96:e7468.
Failure to detect abnormalities during testing can lead to missed or delayed diagnoses. In this retrospective observational study, investigators found that nearly 20% of colonoscopies that needed to be repeated within 6 months had an undetected abnormal finding—a polyp—that was not initially detected. The authors caution that there is significant risk of missing abnormal findings on colonoscopy.
Bsharat S, Drach-Zahavy A. J Adv Nurs. 2017;73:2118-2128.
Patients can play an important role in improving patient safety. Although efforts to engage patients in safety work are becoming more widespread, some have criticized the idea that patients should bear any responsibility for safety. Prior research has shown that parents may help identify safety incidents affecting hospitalized children that might otherwise go undetected, but little is known about how nurses react to parental involvement in safety. This study used attribution theory to better understand how nurses respond to safety issues raised by parents. The authors also discuss the implications of their findings on promoting parental engagement in safety. A past PSNet perspective reviewed the opportunities and limitations when engaging patients in safety.
The ability of staff and clinicians to report concerns about patient safety is key to preventing errors and improving safety. This review explores the evidence on positive and negative consequences of whistleblowing to help guide development of future whistleblowing policies.
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