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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 643 Results

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.
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. 
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.

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.

Kathleen Sanford

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.

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.
WebM&M Case June 28, 2023

A 55-year-old man presented in hypotensive shock, presumably due to bacterial pneumonia superimposed on COPD. The nurse placed an arterial line appropriately in the patient’s radial artery for hemodynamic monitoring, but this line was inadvertently used to infuse an antibiotic. The patient experienced acute arterial thrombosis with resulting hand ischemia but responded to rapid thrombolytic and anticoagulant therapy.

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.
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. 
Tataei A, Rahimi B, Afshar HL, et al. BMC Health Serv Res. 2023;23:527.
Patient handoffs present opportunities for miscommunication and errors. This quasi-experimental study examined the impact of an electronic nursing handover system (ENHS) on patient safety and handover quality among patients both with and without COVID-19 in the intensive care unit (ICU). Findings indicate that the ENHS improved the quality of the handover, reduced handover time, and increased patient safety.
Sparling J, Hong Mershon B, Abraham J. Jt Comm J Qual Patient Saf. 2023;49:410-421.
Multiple handoffs can occur during perioperative care, which can increase the risk for errors and patient harm. This narrative review summarizes research on the benefits, limitations, and implementation challenges of electronic tools for perioperative handoffs and the role of artificial intelligence (AI) and machine learning (ML) in perioperative care.
Alqenae FA, Steinke DT, Carson-Stevens A, et al. Ther Adv Drug Saf. 2023;14:204209862311543.
Medication errors and adverse drug events (ADE) are unfortunately common at hospital discharge. This study used the National Reporting and Learning System (NRLS) in England and Wales to identify contributing causes to medication errors and ADE. Patients over 65 were the most common age group and, of incidents with a stated level of harm, most did not result in any harm. Overall, most incidents occurred at the prescribing stage, but varied by patient age group. Most contributory factors were organizational (e.g., continuity of care between provider types), followed by staff, patient, and equipment factors.
Patient Safety Innovation May 31, 2023

Seeking a sustainable process to enhance their hospitals’ response to sepsis, a multidisciplinary team at WellSpan Health oversaw the development and implementation of a system that uses customized electronic health record (EHR) alert settings and a team of remote nurses to help frontline staff identify and respond to patients showing signs of sepsis. When the remote nurses, or Central Alerts Team (CAT), receive an alert, they assess the patient’s information and collaborate with the clinical care team to recommend a response.

Farnborough, UK: Healthcare Safety Investigation Branch; April 2023.

Gaps in patient information processes can result in missed care opportunities that contribute to harm. This report examines language discordance in National Health Service written scheduling communications and its contribution to patients being lost to follow up. The primary improvement recommendation is to enhance the ability of providers to recognize primary languages of patients and provide written instructions accordingly.
Yanni E, Calaman S, Wiener E, et al. J Healthc Qual. 2023;45:140-147.
I-PASS is a structured handoff tool that aims to improve communication and reduce adverse events during transitions of care. This article describes the implementation of a modified I-PASS tool for use in the emergency department (ED I-PASS) to improve transitions of care between pediatric emergency medicine physicians. Implementation of ED I-PASS decreased the perceived loss of key patient information during transitions of care (from 75% to 37.5%).
Karlic KJ, Valley TS, Cagino LM, et al. Am J Med Qual. 2023;38:117-121.
Because patients discharged from the intensive care unit (ICU) are at increased risk of readmission and post-ICU adverse events, some hospitals have opened post-ICU clinics. This article describes safety threats identified by post-ICU clinic staff. Medication errors and inadequate medical follow-up made up nearly half of identified safety threats. More than two-thirds were preventable or ameliorable.
Coghlan A, Turner S, Coverdale S. Intern Med J. 2023;53:550-558.
Use of abbreviations in electronic health records increases risk of misunderstandings, particularly between providers of different specialties. In this study, junior doctors and general practitioners were asked about their understanding of common, uncommon, and rare abbreviations used in hospital discharge notes. No abbreviation was interpreted in the same way by all respondents, and nearly all respondents left at least one abbreviation blank or responded that they didn't know.
Donzé JD, John G, Genné D, et al. JAMA Internal Med. 2023;183:658-668.
Adverse events and unplanned, preventable readmissions occur in approximately 20% of patients following discharge from the hospital. This randomized clinical trial compares standard care with a multi-modal discharge intervention targeting patients at highest risk of unplanned readmission. Despite the intensity of the intervention, there was no statistical difference between that intensity and the standard of care in unplanned readmission, time to readmission, or death.
Mills PD, Louis RP, Yackel E. J Healthc Qual. 2023;45:242-253.
Changes in healthcare delivery due to the COVID-19 pandemic resulted in delays in care that can lead to patient harm. In this study using patient safety event data submitted to the VHA National Center of Patient Safety, researchers identified healthcare delays involving laboratory results, treatment and interventional procedures, and diagnosis.   
Perspective on Safety April 26, 2023

Throughout 2022, AHRQ PSNet has shared research that elucidates the complex nature of misdiagnosis and diagnostic safety. This Year in Review explores recent work in diagnostic safety and ways that greater safety may be promoted using tools developed to improve diagnostic practices.

Throughout 2022, AHRQ PSNet has shared research that elucidates the complex nature of misdiagnosis and diagnostic safety. This Year in Review explores recent work in diagnostic safety and ways that greater safety may be promoted using tools developed to improve diagnostic practices.

King CR, Shambe A, Abraham J. JAMIA Open. 2023;6:ooaf015.
Handoffs and transitions of care represent a vulnerable time for patients as important information must be shared and understood by multiple people. This study focuses on postoperative nurse handoffs, specifically regarding situational awareness and anticipatory guidance, and the role artificial intelligence (AI) could play in improving handoffs. Five themes were uncovered, including the importance of situational awareness and associated barriers, how AI could address those barriers, and how AI could result in new/additional barriers.