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.
Lyndon A, Simpson KR, Spetz J, et al. Appl Nurs Res. 2022;63:151516.
Missed nursing care appears to be associated with higher rates of adverse events. More than 3,600 registered nurses (RNs) were surveyed about missed care during labor and birth in the United States. Three aspects of nursing care were reported missing by respondents: thorough review of prenatal records, missed timely documentation of maternal-fetal assessments, and failure to monitor input and output.
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...
Desai S, Fiumara K, Kachalia A. J Patient Saf. 2021;17:e84-e90.
Outpatient safety is gaining recognition as a focus of research and improvement efforts. This project report describes an ambulatory safety program at an academic health system that targeted reporting, safety culture measurement, medication safety, and test result management. Repeated tracking over a 5-year period revealed that failure to request feedback played a role in the modest incident and concern reporting captured by the program. Decentralizing reporting response responsibilities throughout the system significantly increased feedback activity.
Wolfe HA, Mack EH. Transl Pediatr. 2018;7:267-274.
Pediatric critical care patients are at greater risk for harm. This review examines how a culture of safety affects pediatric critical care delivery and highlights collaboratives as effective mechanisms to develop and test improvement strategies. The authors discuss the development of bundles to reduce hospital-acquired infections and standardize handoffs as promising safety improvement practices.
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.
Emergency departments are high-risk environments due to the urgency of care needs and complexity of communication. This commentary explores challenges associated with medication administration, handoffs, discharge processes, and electronic health records in emergency medicine and recommends strategies to reduce risks.
Sheth S, McCarthy E, Kipps AK, et al. PEDIATRICS. 2016;137.
The I-PASS signout tool has become a widely used method of patient handoffs when transferring care from the primary clinician to a covering clinician. This study used the I-PASS framework to develop and implement a standardized signout process for transferring patients from the pediatric cardiac intensive care unit to the general ward. The new process significantly improved clinician workflow and perceived safety culture relating to handoffs.
Pannick S, Beveridge I, Wachter RM, et al. Eur J Intern Med. 2014;25:874-87.
This narrative review of safety efforts on general hospital wards found that most interventions encompass one or more of five areas: staffing levels, interprofessional collaboration, standardization of care such as use of checklists, rapid response to clinical deterioration, and safety culture. The authors advocate for increasing the evidence base in all of these areas, as gaps in implementation and sustainment are prevalent.
Barber ND, Alldred DP, Raynor DK, et al. Qual Saf Health Care. 2009;18:341-346.
This study found a remarkably high incidence of medication errors—nearly two errors per patient—in skilled nursing facilities. Interviews with staff revealed several underlying factors: polypharmacy, overworked staff, poor communication between nursing home staff and physicians, lack of a culture of safety, and lack of reliable systems for medication ordering and administration. Recognition of the high potential for medication errors in nursing facilities has led to the development of toolkits for improving medication safety. A serious medication administration error at a nursing facility is discussed in this AHRQ WebM&M case commentary.
Desai R, Williams CE, Greene SB, et al. Am J Geriatr Pharmacother. 2011;9:413-22.
Scrutiny over the quality of care delivered in post-acute settings is catalyzing improvement initiatives for this emerging safety priority. Medication safety and fostering a safety culture are previously identified needs, but greater attention to ensure safer care transitions is a targeted goal. This study analyzed medication errors reported by North Carolina nursing homes to describe specific errors that occurred during patient transitions to nursing homes. Of the nearly 30,000 individual medication errors reported, 11% involved a care transition. Notably, the transition-related errors were also associated with higher odds of patient harm. Contributing factors to the transition-related reports included problems with staff communication, order transcription, medication availability, and pharmacy issues. The authors highlight the opportunities for medication safety during this high-risk transition period for patients.
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