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.
Incomplete nursing care can negatively affect care quality and safety. This rapid review found that missed or omitted nursing care in adults contributes to increased mortality, adverse events, and clinical deterioration. Included studies cited several causes (e.g., environmental factors, staffing levels and skill mix) as well as solutions (e.g., education, process redesign).
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.
Blume KS, Dietermann K, Kirchner‐Heklau U, et al. Health Serv Res. 2021;56:885-907.
Nurse staffing levels have been shown to impact patient outcomes. Through an umbrella literature review and expert interviews, researchers developed a list of nurse-sensitive patient outcomes (NSPO). This list provides researchers potential avenues for future studies examining the link between nurse staffing levels and patient outcomes.
Tyler N, Wright N, Panagioti M, et al. Health Expect. 2021;24:185-194.
Transitions of care represent a vulnerable time for patients. This survey found that safety in mental healthcare transitions (hospital to community) is perceived differently by patients, families, and healthcare professionals. While clinical indicators (e.g., suicide, self-harm, and risk of adverse drug events) are important, patients and families also highlighted the social elements of transitional safety (e.g., loneliness, emotional readiness for change).
Mangrum R, Stewart MD, Gifford DR, et al. J Am Med Dir Assoc. 2020;21:1587-1591.e2.
Building upon earlier work, the authors engaged a technical expert panel to reach consensus on a definition for omissions of care in nursing homes. The article details the terms and concepts included in (and excluded from) the proposed definition, provides examples of omissions of care, intended uses (e.g., to guide quality improvement activities or training and education), and describes the implications of the definition for clinical practice, policy, and research.
Salvador RO, Gnanlet A, McDermott C. Personnel Rev. 2020;50:971-984.
Prior research suggests that functional flexibility has benefits in several industries but may carry patient safety risks in healthcare settings. Using data from a national nursing database, this study examined the effect of unit-level nursing functional flexibility on the incidence of hospital-acquired pressure ulcers. Results indicate that higher use of functionally flexible nurses was associated with a higher number of pressure ulcers, but this effect was moderated when coworker support within the unit was high.
Demaria J, Valent F, Danielis M, et al. J Nurs Care Qual. 2021;36:202-209.
Little empirical evidence exists assessing the association of different nursing handoff styles with patient outcomes. This retrospective study examined the incidence of falls during nursing handovers performed in designated rooms away from patients (to ensure confidentiality and prevent interruptions and distractions). No differences in the incidence of falls or fall severity during handovers performed away from patients versus non-handover times were identified.
Handoffs are essential to communicating important information and preventing adverse patient care outcomes. This qualitative study explored how information about ICU patients’ family members is included in handovers. Findings suggest that written documentation about the family is inadequate and poorly structured and there is a need for user-friendly handoff tools that include information on patients’ family members.
Ogletree AM, Mangrum R, Harris Y, et al. J Am Med Dir Assoc. 2020;21:604-614.e6.
To support the development of a uniform definition of omissions of care in nursing home settings, the authors conducted a thematic analysis of 34 articles describing existing definitions and found broad agreement that delays or failure of care constitutes an omission of care, but differing views on whether to include adverse events in the definition of omissions of care. The authors reviewed an additional 327 articles reporting adverse events attributable to omissions of care, and identified nineteen event types, with the most common being all-cause mortality, falls, and infections.
Franklin BJ, Gandhi TK, Bates DW, et al. BMJ Qual Saf. 2020;29:844–853.
Huddles are one technique to enhance team communication, identify safety concerns and built a culture of safety. This systematic review synthesized 24 studies examining the impact of either unit-based or hospital-wide/multiunit safety huddles. The majority of studies were uncontrolled pre-post study designs; only two studies were controlled and quantitatively measured intervention adoption and fidelity. Results for unit-based huddle programs appear positive. Given the limited number of studies evaluating hospital-wide huddle programs, the authors conclude that there is insufficient evidence to assess the benefit. Further research employing strong methodological designs is required to definitively assess the impact of huddle programs.
Sanson G, Marino C, Valenti A, et al. Heart & Lung. 2020;49:407-414.
Prospective observational study examined whether nursing complexity level predicts adverse event risk among patients transferred from the ICU to the discharge ward. In this 13-bed ICU, researchers found that various factors including level of acuity and nursing complexity predated risk of adverse events (AEs); patients who exceeded a predetermined complexity threshold were at 3-times greater risk of AEs.
Trauma patients are particularly vulnerable to medication errors due to the severity of their injuries and the multiple handoffs and transitions often occurring during their hospital stay. This article reviewed existing medication reconciliation strategies and found that many have poor accuracy, can be costly and time-consuming, and may not be applicable to a trauma population. The authors comment on the urgent need for research supporting safe and efficient medication reconciliation in trauma patients.
Rockville, MD: Agency for Healthcare Research and Quality; December 6, 2019. PA-20-068.
Communication during patient transitions carries the potential for mistakes that can result in patient harm. This program (funding) announcement will support the testing of interventions to improve communication and coordination during care transitions within and between a variety of care environments. Applicants are encouraged to incorporate a care transitions model such as Project RED into their research design. Applications are reviewed three times per year- February 5, June 5, and October 5, through 2022
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