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 978 Results

The Risks of a Malpositioned Gastrostomy Tube and Poor Communication

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WebM&M Case November 29, 2023

This case describes a 55-year-old woman who sustained critical injuries after a motor vehicle crash and had a lengthy hospitalization. On hospital day 30, a surgeon placed a percutaneous endoscopic gastrostomy (PEG) tube in the intensive care unit (ICU) after computed tomography (CT) scan showed no interposed bowel between the stomach and the anterior abdominal wall. After the uncomplicated PEG placement, the surgeon cleared the patient’s team to advance tube feeds as tolerated.

The complexities of communication at hospital discharge of older patients: a qualitative study of healthcare professionals' views.

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Cam H, Wennlöf B, Gillespie U, et al. BMC Health Serv Res. 2023;23:1211.

When patients are discharged from the hospital, they (and their informal caregivers) are given copious amounts of information that must also be communicated to their primary care provider. This qualitative study of primary care and hospital physicians, nurses, and pharmacists highlights several barriers to complete and effective communication between levels of care, particularly regarding geriatric medication safety. Barriers include the large number of complex patients and incongruent expectations of responsibility of primary and hospital providers. Support systems, such as electronic health records, can both enable and hinder communication.

Detection rates of mild cognitive impairment in primary care for the United States Medicare population.

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Liu Y, Jun H, Becker A, et al. J Prev Alz Dis. 2023;Epub Oct 24.

Persons with dementia are at increased risk for adverse events compared to those without dementia, highlighting the importance of a timely diagnosis. In this study, researchers estimate approximately 20% of primary care patients aged 65 and older are expected to have a diagnosis of mild cognitive impairment or dementia; however, only 8% have received such a diagnosis. Missed diagnosis prevents patients from receiving appropriate care, including newly FDA-approved medications to slow cognitive decline.

Handoff tool improves transitions from the operating room to the neonatal intensive care unit.

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Gallois JB, Zagory JA, Barkemeyer B, et al. Pediatr Qual Saf. 2023;8:e695.

Structured handoff tools can improve situational awareness and patient safety. This study describes the development and implementation of a bespoke tool for handoffs from the operating room to the neonatal intensive care unit (NICU). While use remained inconsistent during the study period, the goal of 80% compliance was achieved and 83% surveyed staff agreed or strongly agreed that the handoff provided needed information, up from 21% before implementation.

On Patient Safety.

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Rickert J, Järvinen TLN, Lee MJ, et al. Clin Orthop Relat Res. 2013-2023.

This quarterly commentary explores a wide range of subjects associated with patient safety, such as the impact of disruptive behavior on teams, the value of apologies, and safety challenges inherent in clinician strike actions. Older materials are available online for free.

Delay in Malignancy Diagnosis Reflects Systemic Failures.

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WebM&M Case October 31, 2023

A 32-year-old man presented to the hospital with a comminuted midshaft femoral fracture after a bicycle accident. Imaging suggested the fracture was pathologic and an open biopsy specimen was submitted to pathology for intraoperative consultation.

Beyond the surgical safety checklist: using intraoperative handoff to facilitate team situation awareness in the OR.

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Ramjaun A, Hammond Mobilio M, Wright N, et al. Ann Surg. 2023;278:e1142-e1147.

Situational awareness is an essential component of teamwork. This qualitative study examined how situational awareness and team culture impact intraoperative handoff practice. Researchers found that participants often assumed that team members are interchangeable and that trained staff should be able to determine handoff appropriateness without having to consult the larger operating room team – both of these assumptions hinder team communication and situational awareness.

TeamSTEPPS Master Training Course.

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Armstrong Institute for Patient Safety and Quality. January 30 and February 1, 2024.

Team training programs seek to improve communication and coordination among team members to reduce the potential for medical error. This virtual workshop will train participants to design, implement, and evaluate team training programs in their organizations based on the TeamSTEPPS model.

Curated Libraries

Patient as a Team Member in Clinical Care

October 23, 2023

This curated library highlights concepts associated with the patient as a partner for safety at the team level directly connected to personal clinical encounters.

A scoping review of clinical handover mnemonic devices.

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Yung AHW, Pak CS, Watson B. Int J Qual Health Care. 2023;35:mzad065.

Cognitive aids such as mnemonics can help improve process reliability and promote patient safety. Based on an initial scoping review, this article describes a proposed taxonomy for clinical handoff mnemonics and their clinical processes and functions, which could help clinical teams design handoff mnemonics that best fit their workplace.

Multicomponent pharmacist intervention did not reduce clinically important medication errors for ambulatory patients initiating direct oral anticoagulants.

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Kapoor A, Patel P, Mbusa D, et al. J Gen Intern Med. 2023;Epub Sep 27.

Pharmacists are frequently involved in medication reviews for hospitalized patients prescribed direct oral anti-coagulants (DOAC). This randomized controlled study explored pharmacist involvement with patients prescribed DOAC in ambulatory care. The intervention included up to three phone calls, electronic health record communication with the prescriber, and recommendations for lab work. After 90 days, there were no differences in clinically important medication errors between groups.

Reduced postdischarge incidents after implementation of a hospital-to-home transition intervention for children with medical complexity.

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Huth K, Hotz A, Emara N, et al. J Patient Saf. 2023;19:493-500.

The transition from hospital to home is a vulnerable time as patients may have changes in medications or care needs, or difficulties accessing follow up with an outpatient provider. To reduce adverse events (AE), rehospitalizations, and emergency department visits, this hospital developed a structured discharge bundle based on the I-PASS tool used for inpatient handoffs. AE, rehospitalizations, and emergency department visits were all reduced following implementation of the I-PASS bundle.

Scaling up a diagnostic pause at the ICU-to-ward transition: an exploration of barriers and facilitators to implementation of the ICU-PAUSE handoff tool.

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Cornell EG, Harris E, McCune E, et al. Diagnosis (Berl). 2023;10:417-423.

Structured handoffs can improve the quality of patient information passed from one care team to another. This article describes intensivists' perspectives on a potential handoff tool (ICU-PAUSE) for handoff from the intensive care unit (ICU) to medical ward. They described the usefulness of a structured clinical note, especially regarding pending tests and the status of high-risk medications. Several barriers were also discussed, such as the frequent training required for residents who rotate in and out of the ICU and potential duplication of the daily chart note.

Radiographers' experience of preventing patient safety incidents in the context of radiological examinations.

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Wallin A, Ringdal M, Ahlberg K, et al. Scand J Caring Sci. 2023;37:414-423.

Numerous factors can hinder safe radiology practices, such as communication failures and image interpretation errors. Based on semi-structured interviews with 17 radiologists in Sweden, this study identified 20 themes at the individual-, organization-, technology-, task-and environment-levels describing factors supporting patient safety in radiology. Factors described by participants included the use of standardized tools and work routines (e.g., checklists), handoffs, and incident reporting systems.

Work system barriers and facilitators of a team health information technology.

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Hose B-Z, Carayon P, Hoonakker PLT, et al. Appl Ergon. 2023;113:104105.

Health information technology (IT) usability continues to be a source of patient harm. This study describes the perspectives of a variety of pediatric trauma team members (e.g., pediatric emergency medicine attending, surgical technician, pediatric intensive care unit attending) on the usability of a potential team health IT care transition tool. Numerous barriers and facilitators were identified and varied across department and role.

Long-term sustainability and adaptation of I-PASS handovers.

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Ryan SL, Logan M, Liu X, et al. Jt Comm J Qual Patient Saf. 2023;19:689-697.

I-PASS is a structured tool to improve handoffs and communication between clinicians and promote patient safety. This study examined I-PASS implementation practices over a six-year period in 10 departments at one large academic medical center. Researchers found that most clinical services successfully implemented I-PASS and those using I-PASS conducted the most efficient handovers.

‘The Retrievals’ reveals painful experiences of female patients are often ignored.

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Desjardins L. PBS NewsHour. August 29, 2023.

Disregard for women’s pain is a persistent problem in health care. This news segment discusses a podcast highlighting a pattern of dismissal of patient concerns that resulted in harm and allowed fentanyl diversion by a nurse with substance abuse disorder to go undetected.

Intraoperative communications between pathologists and surgeons: do we understand each other?

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Wiggett A, Fischer G. Arch Pathol Lab Med. 2023;147:933-939.

Miscommunication between pathologists and surgeons can lead to significant patient harm. This study identified multiple discrepancies between pathologist-listed diagnoses included in intraoperative consult notes compared to surgeon-dictated operative notes. Discrepancies were most common in multipart cases and those involving deferrals.

Video review of simulated pediatric cardiac arrest to identify errors/latent safety threats: a mixed methods study.

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Garcia-Jorda D, Nikitovic D, Gilfoyle E. Simul Healthc. 2023;18:232-239.

Simulation trainings are widely used to identify safety threats and improve processes. By analyzing video recordings of pediatric cardiac arrest simulations, researchers were able to identify 5 main areas of errors: clinical, planning and execution, communication, distraction, and knowledge/training. Investigating the root causes of these errors can result in improved trainings and, thus, improved patient outcomes.

Virtual Nursing: Improving Patient Care and Meeting Workforce Challenges

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Perspective on Safety August 30, 2023

This piece discusses virtual nursing, an approach to care that incorporates an advanced practice nurse into hospital-based patient care through telehealth. Virtual nursing increases patient safety and may enable expert nurses to continue to meet patient needs in future staffing shortages.

In Conversation with Kathleen Sanford and Sue Schuelke about Virtual Nursing

Editor’s note: Kathleen Sanford is the chief nursing officer and an executive vice president at CommonSpirit. Sue Schuelke is an assistant professor at the College of Nursing–Lincoln Division, University of Nebraska Medical Center. They have pioneered and tested a new model of nursing care that utilizes technology to add experienced expert nurses to care teams, called Virtual Nursing.

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