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.
The change of an inpatient’s location or handoffs between teams can fragment care due to communication, information, and knowledge gaps. This review examines in-patient transition safety issues and summarizes system level, sender, and receiver tactics to reduce patient vulnerability during handoffs.
Vollam S, Gustafson O, Morgan L, et al. Crit Care Med. 2022;50:1083-1092.
This mixed-method study explored the reasons why out-of-hours discharges from the ICU to the ward, and nighttime coverage are associated with poor outcomes. Based on qualitative interviews with patients, family members, and staff involved in the ICU discharge process, this study found that out-of-hours discharges are considered unsafe due to nighttime staffing levels and skill mix. Out-of-hours discharges often occurred prematurely, without adequate handovers, and involved patients who were not physiologically stable, and at risk for clinical deterioration.
Shafer GJ, Singh H, Thomas EJ, et al. J Perinatol. 2022;42:1312-1318.
Patients in the neonatal intensive care unit (NICU) are at risk for serious patient safety threats. In this retrospective review of 600 consecutive inborn NICU admissions, researchers found that the frequency of diagnostic errors among inborn NICU patients during the first seven days of admission was 6.2%.
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...
Hensgens RL, El Moumni M, IJpma FFA, et al. Eur J Trauma Emerg Surg. 2020;46:1367-1374.
Missed injuries and delayed diagnoses are an ongoing problem in trauma care. This cohort study conducted at a large trauma center found that inter-hospital transfer of severely injured patients increases the risk of delayed detection of injuries. For half of these patients, the new diagnoses led to a change in treatment course. These findings highlight the importance of clinician vigilance when assessing trauma patients.
Arshad SA, Ferguson DM, Garcia EI, et al. J Surg Res. 2021;257:455-461.
Engaging patients and families is an important strategy in ensuring safe health care delivery. In this prospective, observational study, use of a parent-centered script did not improve parent engagement during the preinduction checklist and resulted in an expected decline in checklist adherence.
Kannampallil TG, Abraham J. JAMIA Open. 2020;3:87-93.
Prior research has found that many clinicians do not engage in active listening behaviors essential to safe patient care. This prospective observational study used a mixed-methods approach to better understand listening and question-asking behaviors during residents and nurses handoffs. The researchers did not identify any significant differences between residents and nurses in their active or passive listening behaviors, but they did find that nurses asked significantly more questions than residents.
Care transitions increase the risk of patient safety events, and pediatric patients are particularly vulnerable. This study used the Systems Engineer Initiative for Patient Safety approach to analyze care transitions, identify system barriers and solutions to guide efforts towards improving care transitions. Nine dimensions of system barriers and facilities in care transitions were identified: anticipation; ED decision making; interacting with family; physical environment; role ambiguity; staffing/resources; team cognition; technology, and; characteristics of trauma care. Understanding these barriers and facilitators can guide future endeavors to improve care transitions.
Patient safety is a concern throughout the entire process of care from admission to discharge. This article highlights the role of risk managers to assure that patients return to a home environment that can enable their safe recovery whether the discharge is advised or not.
Schmidt T, Kocher DR, Mahendran P, et al. Stud Health Technol Inform. 2019;267:224-229.
Structured communication methods such as SBAR (situation, background, assessment, recommendation) or ISBAR (identify, situation, background, assessment, recommendation)
were developed to improve handoffs in the hospital, particularly from nursing to physicians, and to reduce the impact of poor communication on adverse events. This study presents a digital pocket card incorporating ISBAR standards that can be used by nurses to facilitate patient handoffs and reporting.
Pandya C, Clarke T, Scarsella E, et al. J Oncol Pract. 2019;15:e480-e489.
Care transitions and handoffs represent a vulnerable time for patients, as failure to communicate important clinical information may occur with the potential for harm. In this pre–post study, researchers found that implementation of an electronic health record tool designed to improve the handoff between oncology clinic and infusion nurses was associated with a reduction in medication errors, shorter average patient waiting time, and better communication between nurses.
Alimenti D, Buydos S, Cunliffe L, et al. J Am Assoc Nurse Pract. 2019;31:354-363.
This systematic review of handoffs from the emergency department to inpatient settings found that standardized handoff approaches led to enhanced perceptions of safety and satisfaction. Researchers found that little data exists on the impact of standardizing handoffs from the emergency department to the hospital on safety outcomes, but studies demonstrated the potential for provider education and implementation of standardized handoff tools to positively affect perceptions of patient safety and provider satisfaction.
Hendrickson MA, Schempf EN, Furnival RA, et al. Jt Comm J Qual Patient Saf. 2019;45:431-439.
This project report describes a novel procedure for handoffs from the emergency department to the inpatient service. The study team implemented a daily conference call that included nurses, residents, and attending physicians rather than separating physician and nursing handoff workflows. The overall reaction to the interdisciplinary workflow was positive.
Umberfield E, Ghaferi AA, Krein SL, et al. Jt Comm J Qual Patient Saf. 2019;45:406-413.
Communication failures are a common underlying factor in adverse events. Although the relationship between communication failures and safety has been best studied in the operating room, this issue likely contributes to safety problems in all settings of care. Investigators examined incident reports at an academic medical center to characterize how communication problems contribute to adverse events. Errors of purpose—a type of error in which the goals of the communication event remain unresolved, implying that situational awareness was not achieved—were among the most common types of communication problems identified. The authors point out that while structured communication tools (such as the I-PASS handoff tool) can improve the accuracy and completeness of information transfer, they are not well suited to improving communication in clinically ambiguous situations. Communication problems most often led to delays in care without physical harm, highlighting the difficulty of measuring communication issues compared to other types of safety events. A WebM&M commentary discussed a series of communication errors that led to a child's death.
Mistakes during handoffs from the emergency department (ED) to inpatient units can diminish patient safety. This commentary summarizes how one hospital sought to to avoid miscommunications and disruptions by blocking admission of ED transfers during shift report. However, researchers found that blocking patient transfers did not result in improvements. The project did devise a standardized handoff process that was ultimately employed across the organization as a patient safety strategy.
Larson LA, Finley JL, Gross TL, et al. Jt Comm J Qual Patient Saf. 2019;45:74-80.
Workplace violence in the health care setting is common and poses an ongoing risk for providers and staff. The Joint Commission issued a sentinel event alert to raise awareness about the risks associated with physical and verbal violence against health care workers and suggests numerous strategies organizations can use to address the problem, including establishing reporting systems and developing quality improvement interventions. The authors describe a quality improvement initiative involving the development and iterative testing of a huddle handoff tool to optimize communication between the emergency department (ED) and an admitting unit regarding patients with the potential for violent behavior. The huddle tool led to improved perceptions of safety during the patient transfer process by both the ED nurses and the admitting medical units. An accompanying editorial highlights the importance of taking a systems approach to address workplace safety. A PSNet perspective explored how a medical center developed a process to identify, prioritize, and mitigate hazards in health care settings.
Campbell D, Dontje K. Journal of emergency nursing: JEN : official publication of the Emergency Department Nurses Association. 2019;45:149-154.
Handoffs in the emergency department are vulnerable to error. This commentary describes an improvement initiative that focused on structuring nurse shift change using situation, background, assessment, recommendation (SBAR) communication methods. Although safety culture scores improved, the authors note that resistance to change was a key barrier to implementation.
Although team development has received increased attention in health care, miscommunications that affect patient safety continue to occur. This commentary reviews factors that contribute to poor communication behaviors among perioperative nurses and summarizes guidance on how to improve team communication, such as use of standardized checklists and briefings.
Starmer AJ, Schnock KO, Lyons A, et al. BMJ Qual Saf. 2017;26:949-957.
Handoffs increase the risk of adverse events, mainly due to lapses in communication. Implementation of a standardized approach to handoffs may help improve patient safety. This prospective pre–post intervention study examined the impact of a multicomponent handoff intervention consisting of education, verbal handoff mnemonic implementation (I-PASS), and visual aids on nursing handoffs. Researchers used assessment tools to evaluate both the quality and duration of handoffs. Implementation of the intervention was associated with an overall improvement in the handoff process and did not adversely impact nursing workflow. A previous Annual Perspective highlighted safety issues related to handoffs and care transitions.
Small A, Gist D, Souza D, et al. J Nurs Care Qual. 2016;31:304-9.
Change management has been described as a critical strategy to ensure safety improvements are sustained. This commentary discusses how one hospital applied a well-known change model to implement a new bedside handoff process and reports positive reactions from nurses and patients one month after the intervention.
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