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 86 Results

Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions

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Perspective on Safety November 16, 2022

Human factors engineering or ergonomics (HFE) is a scientific discipline broadly focused on interactions among humans and other elements of a system.

In Conversation with Dr. Michelle Schreiber on Measuring Patient Safety

We spoke to Dr. Michelle Schreiber about measuring patient safety, the CMS National Quality Strategy, and the future of measurement. Michelle Schreiber, MD, is the Deputy Director of the Center for Clinical Standards and Quality and the Director of the Quality Measurement and Value-Based Incentives Group at the Centers for Medicare & Medicaid Services.

Identifying Safety Events in the Prehospital Setting

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Perspective on Safety May 16, 2022

This piece focuses on measuring and monitoring patient safety in the prehospital setting.

In Conversation With... Remle P. Crowe, PhD

Remle Crowe, PhD, NREMT, is the Director of Clinical and Operational Research at ESO. In her professional role, she provides strategic direction for the research mission of the organization, including oversight of a warehouse research data set of de-identified records (the ESO Data Collaborative). We spoke with her about how data is being used in the prehospital setting to improve patient safety.

Curated Libraries

Maternal Safety

September 13, 2021

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, collaborative initiatives, teamwork, and trigger tools.

Missed acute coronary syndrome during telephone triage at out-of-hours primary care: lessons from a case-control study.

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Erkelens DC, Rutten FH, Wouters LT, et al. J Patient Saf. 2022;18:40-45.

Delays in diagnosis and treatment during after-hours care pose serious threats to patient safety. This case-control study compared missed acute coronary syndrome (ACS) cases to other cases with chest discomfort occurring during out-of-hours services in primary care. Predictors of missed ACS included the use of cardiovascular medication, non-retrosternal chest pain, and consultation of the supervising general practitioner.

Speaking up about patient-perceived serious visit note errors: patient and family experiences and recommendations.

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Lam BD, Bourgeois FC, Dong ZJ, et al. J Am Med Inform Assoc. 2021;28:685-694.

Providing patients access to their medical records can improve patient engagement and error identification. A survey of patients and families found that about half of adult patients and pediatric families who perceived a serious mistake in their ambulatory care notes reported it, but identified several barriers to reporting (e.g. no clear reporting mechanism, lack of perceived support).

The effect of virtual nursing and missed nursing care.

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Schuelke S, Aurit S, Connot N, et al. Nurs Adm Q. 2020;44:280-287.

The COVID-19 pandemic increased delivery of virtual care through mechanisms such as remote triage and video consultation. This article describes the results of a multi-site study examining the impact of a virtual nursing care team on missed nursing care. Findings indicate the missed care and reasons for missed care remained consistent during pre- and post-implementation, and further research is necessary to explore the impact of virtual nursing.

The Need to Eat

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WebM&M Case December 18, 2019

A 62-year-old man with a history of malnutrition-related encephalopathy was admitted for possible aspiration pneumonia complicated by empyema and coagulopathy. During the hospitalization, he was uncooperative and exhibited signs of delirium. For a variety of reasons, he spent two weeks in the hospital with minimal oral intake and without receiving most of his oral medications, putting him at risk for complications and adverse outcomes.

Patient Safety 101

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Patient Safety Primer September 7, 2019

This Primer provides an overview of the history and current status of the patient safety field and key definitions and concepts. It links to other Patient Safety Primers that discuss the concepts in more detail.

Ensuring effective care transition communication: implementation of an electronic medical record-based tool for improved cancer treatment handoffs between clinic and infusion nurses.

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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.

An opportunity to engage obstetrics and gynecology patients through shared visit notes.

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Herlihy M, Harcourt K, Fossa A, et al. Obstet Gynecol. 2019;134:128-137.

Prior research has shown that when patients have access to clinicians' notes, they may identify relevant safety concerns. In this study, 9550 obstetrics and gynecology patients were provided with access to their outpatient visit documentation. Almost 70% of eligible patients read one or more notes during the study period, but only 3.2% shared feedback through 232 electronic reports. Of patients who provided feedback, 27% identified errors in the documentation; provider reviewers determined that 75% of these could impact care.

Delayed Sepsis Management Due to Ambiguous Allergy

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WebM&M Case June 1, 2019

Transferred to the emergency department from the transfusion center after becoming unresponsive and hypotensive, an elderly man with signs of sepsis is given incomplete and delayed antimicrobial coverage due to a history of penicillin allergy. Neither gram-negative nor anaerobic coverage were provided until several hours later, and the patient developed septic shock.

Duplicate Insulin Order

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WebM&M Case March 1, 2019

Seen in the emergency department, a man with insulin-dependent diabetes mellitus had not taken insulin for 3 days. His blood glucose levels were in the 800s with an anion-gap acidosis and positive beta hydroxybutyrate. While awaiting an ICU bed for treatment of diabetic ketoacidosis, the patient received fluids, an insulin drip was started, and blood glucose levels were monitored hourly. When lab results showed he was improving, the team decided to convert his insulin drip to subcutaneous long-acting insulin.

The effect of a clinical decision support for pending laboratory results at emergency department discharge.

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Driver BE, Scharber SK, Fagerstrom ET, et al. J Emerg Med. 2019;56:109-113.

This pre–post study examined the effect of an electronic health record alert that required physicians to respond "yes" or "no" regarding whether tests were pending at the time of discharge from the emergency department. Investigators found that physician responses were often inaccurate, and the proportion of discharged patients with tests pending increased following the intervention, contrary to intentions.

Triaging Interhospital Transfers

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WebM&M Case February 1, 2019

To transfer a man with possible sepsis to a hospital with subspecialty and critical care, a physician was unaware of a formal protocol and called a colleague at the academic medical center. The colleague secured a bed, and the patient was sent over. However, neither clinical data nor the details of the patient's current condition were transmitted to the hospital's transfer center, and the receiving physician booked a general ward bed rather than an ICU bed. When the patient arrived, his mentation was altered and breathing was rapid.

Perioperative medication errors: uncovering risk from behind the drapes.

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Cierniak KH, Gaunt MJ, Grissinger M. PA-PSRS. Patient Saf Advis. 2018;15(4).

The operating room environment harbors particular patient safety hazards. Drawing from 1137 perioperative medication error reports submitted over a 1-year period, this analysis found that more than half of the recorded incidents reached the patient and the majority of those stemmed from communication breakdowns during transitions or handoffs. The authors provide recommendations to reduce risks of error, including using barcode medication administration, standardizing handoff procedures, and stocking prefilled syringes.

Prospective daily review of discharge medications by pharmacists: effects on measures of safety and efficiency.

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Craynon R, Hager DR, Reed M, et al. Am J Health Syst Pharm. 2018;75:1486-1492.

Pharmacists are expanding their reach as stewards of medication safety into the front line of care. This project report describes the pilot testing of pharmacist involvement in development and review of medication orders in the discharge workflow. A substantive percentage of medication problems were prevented due to pharmacist engagement.

Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors.

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Gupta A, Harrod M, Quinn M, et al. Diagnosis (Berl). 2018;5:151-156.

This direct observation study of hospitalist teams on rounds and conducting follow-up work examined the interaction between systems problems and cognitive errors in diagnosis. Researchers found that information gaps related to electronic health records, challenges with handoffs, and time constraints all contributed to difficulties in diagnostic cognition. The authors suggest considering both systems and cognitive challenges to diagnosis in order to promote safety.

Challenges in communication from referring clinicians to pathologists in the electronic health record era.

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Barbieri AL, Fadare O, Fan L, et al. J Pathol Inform. 2018;9:8.

This secondary data analysis of electronic health record (EHR) messages addressed to pathologists uncovered gaps in clinician-to-clinician communication. A range of clinicians used the EHR to ask clinical questions of pathologists, and pathologists largely did not use the EHR message inbox. The authors suggest that design and implementation of electronic tools should anticipate and address these potential safety problems.

Ward round template: enhancing patient safety on ward rounds.

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Gilliland N, Catherwood N, Chen S, et al. BMJ Open Qual. 2018;7:e000170.

Incomplete communication regarding patient information can diminish the safety of care delivery. This commentary describes how a quality improvement project applied plan–do–study–act cycles to enhance collection of patient data. Researchers developed, tested, and refined a ward round template in a United Kingdom urology service and increased compliance in the recording of patient care measures.

The need for closed-loop systems for management of abnormal test results.

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Zuccotti G, Samal L, Maloney FL, et al. Ann Intern Med. 2018;168:820-821.

Failure to follow up abnormal test results can lead to a delayed or missed diagnosis. Using data from a single institution, researchers observed that while more than 99% of abnormal mammograms received appropriate follow-up, only 91% of abnormal Papanicolaou (Pap) smears did. They suggest that improving workflow processes and ensuring appropriate use of health information technology can help optimize test result follow-up.

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