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 164 Results

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.

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.

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.

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.

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.

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.

Prolonged DKA in Pregnancy: A Case of Communication Breakdown.

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WebM&M Case August 30, 2023

A 31-year-old pregnant patient with type 1 diabetes on an insulin pump was hospitalized for euglycemic diabetic ketoacidosis (DKA). She was treated for dehydration and vomiting, but not aggressively enough, and her metabolic acidosis worsened over several days. The primary team hesitated to prescribe medications safe in pregnancy and delayed reaching out to the Maternal Fetal Medicine (MFM) consultant, who made recommendations but did not ensure that the primary team received and understood the information.

Clinicians' insights on emergency department boarding: an explanatory mixed methods study evaluating patient care and clinician well-being.

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Loke DE, Green KA, Wessling EG, et al. Jt Comm J Qual Patient Saf. 2023;49:663-670.

Quantitative studies have demonstrated that emergency department (ED) overcrowding and patient boarding contribute to adverse events. This study includes both qualitative and quantitative methods to understand how ED clinicians view the impact of boarding on their own well-being as well as patient safety. Key themes include clinician dissatisfaction and burnout, and high rates of verbal and physical abuse from boarding patients. Possible solutions included improved standardization of care, proactive planning, and culture change hospital-wide.

Patient safety in palliative care at the end of life from the perspective of complex thinking.

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Bittencourt NCC de M, Duarte S da CM, Marcon SS, et al. Healthcare (Basel). 2023;11:2030.

Adverse events in palliative care can include inappropriate pain management, preventable hospital (re)admissions, falls, and pressure injuries. This paper outlines ways palliative care is not always received timely, the uniqueness of patient safety within palliative care, and how to raise awareness of both of these issues for healthcare providers, educators, and patients and families.

Improving emergency medicine clinician awareness of prehospital-administered medications.

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Kamta J, Fregoso B, Lee A, et al. Prehosp Emerg Care. 2023;Epub Jul 28.

Handoffs from emergency medical services (EMS) to the emergency department (ED) are vulnerable to communication errors due to the time-pressured environment. This study reports on the implementation of an electronic health record (EHR) tool that added pre-hospital medication administration to the ED triage note to reduce medication administration errors (MAE). Although most ED providers reported they "always" review the triage note, MAE rates did not improve following implementation.

Improving handoffs in the perioperative environment: a conceptual framework of key theories, system factors, methods, and core interventions to ensure success.

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Starmer AJ, Michael MM, Spector ND, et al. Jt Comm J Qual Patient Saf. 2023;49:384-393.

Multiple handoffs during perioperative care present opportunities for error. This article outlines a conceptual framework to support the development, implementation, and evaluation of patient-centered handoffs during perioperative care. The authors describe a multi-component handoff improvement bundle including mnemonics and checklists (such as I-PASS), technology solutions to reinforce verbal handoffs, interprofessional handoff training and assessment, and leadership support to promote safety culture.

Widespread misinterpretation of advance directives and Portable Orders for Life-Sustaining Treatments threatens patient safety and causes undertreatment and overtreatment.

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Mirarchi FL, Pope TM. J Patient Saf. 2023;19:289-292.

Providing treatment that is discordant with patients’ preferences for end-of-life care can lead to unnecessary or unwanted treatment. This article summarizes the incidence of treatment discordant with their Portable Orders for Life Sustaining Treatment (POLST) and advanced directives (ADs) and tools for use by clinicians and patients and family members to promote concordant care. A previous PSNet WebM&M Spotlight Case discusses the importance of advanced care planning and the consequences of inadequate communication and planning for end-of-life care.

Leveraging the science of teamwork to sustain handoff improvements in cardiovascular surgery.

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Keebler JR, Lynch I, Ngo F, et al. Jt Comm J Qual Patient Saf. 2023;49:373-383.

Handoffs are an inevitable part of hospital care; clear communication between providers is required to ensure safe care. This quality improvement project aimed to improve handoffs between the cardiovascular (CV) operating room and CV intensive care unit by developing, implementing, and sustaining a structured handoff bundle. A participatory design was used to ensure that the tool contained only the key elements to support implementation without overburdening users.

So many ways to be wrong: completeness and accuracy in a prospective study of OR-to-ICU handoff standardization.

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Conn Busch J, Wu J, Anglade E, et al. Jt Comm J Qual Patient Saf. 2023;49:365-372.

Structured handoffs are recognized as a method to ensure that complete, accurate information is shared between teams. This article describes the impact of the Handoffs and Transitions in Critical Care (HATRICC) study on accuracy and completeness of handoff before and after implementation of a structured handoff tool. Post-intervention, the accuracy and completeness of handoffs improved. Omissions, mortality, and length of intensive care unit (ICU) stay were reported in a 2019 study.

Diagnostic Safety Across Transitions of Care Throughout the Healthcare System: Current State and a Call to Action.

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Santhosh L, Cornell E, Rojas JC, et al. Rockville, MD: Agency for Healthcare Research and Quality; June 2023. AHRQ Publication No. 23-0040-1-EF.

Care transitions present opportunities for errors. This issue brief highlights the risk of diagnostic errors during transitions in care, such as from the emergency department to the inpatient floor or from inpatient to outpatient care. The brief describes strategies to prevent and reduce these errors, such as diagnostic feedback or structured handoff tools.

Patient safety perception within hospitals: an examination of job type, handoffs and information exchange, and hospital management support.

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Ming Y, Meehan R. J Patient Saf. 2023;19:369-374.

Health care workers’ perception of safety is an important indicator of safety culture. Using data from the 2021 AHRQ Hospital Survey on Patient Safety Culture™ (SOPS®), these researchers examined individual and organizational factors influencing perceived patient safety ratings. Findings indicate that nurses have lower patient safety perceptions compared to other job types and that organizational factors such as organizational learning, leadership support, and ease of handoffs and information exchange, were all associated with higher perceived patient safety.

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