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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 39 Results

Järvinen TLN, Rickert J, Lee MJ, et al. Clin Orthop Relat Res. 2013-2022.

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 due to COVID-19. Older materials are available online for free.
Fitzgerald KM, Banerjee TR, Starmer AJ, et al. Pediatr Qual Saf. 2022;7:e539.
I-PASS is a structured handoff tool designed to improve communication between teams at change-of-shift or between care settings. This children’s hospital implemented an I-PASS program to improve communication between attending physicians and safety culture. One year after the program was introduced, all observed handoffs included all five elements of I-PASS and the duration of handoff did not change. Additionally, the “handoff and transition score” on the Agency for Healthcare Quality (AHRQ) Hospital Survey on Patient Safety Culture improved.
Galatzan BJ, Carrington JM. Res Nurs Health. 2021;44:833-843.
During handoffs, nurses are exposed to a variety of interruptions and distractions which may lead to cognitive overload. Using natural language processing, researchers analyzed ten audio-recorded change of shift handoffs to estimate the cognitive load experienced by nurses. Nurses’ use of concise language has the potential to decrease cognitive overload and improve patient outcomes.
Lafferty M, Harrod M, Krein SL, et al. J Am Med Inform Assoc. 2021;28:28(12).
Use of one-way communication technologies, such as pagers, in hospitals have led to workarounds to improve communication. Through observation, shadowing, interviews, and focus groups with nurses and physicians, this study describes antecedents, types, and effects of workarounds and their potential impact on patient safety.
Patient Safety Primer April 21, 2021
Nurses play a critical role in patient safety through their constant presence at the patient's bedside. However, staffing issues and suboptimal working conditions can impede a nurse’s ability to detect and prevent adverse events.
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.
Olmstead J. Nurs Manage. 2019;50:8-10.
Mistakes during handoffs from the emergency department (ED) to inpatient units can diminish patient safety. This commentary summarizes how one hospital sought to to avoid miscommunications and disruptions by blocking admission of ED transfers during shift report. However, researchers found that blocking patient transfers did not result in improvements. The project did devise a standardized handoff process that was ultimately employed across the organization as a patient safety strategy.
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.
Matern LH, Farnan JM, Hirsch KW, et al. Simul Healthc. 2018;13:233-238.
Training resident physicians to use structured handoff tools reduces errors in the care of hospitalized patients. Researchers developed a handoff simulation incorporating the types of noise and distractions that are ubiquitous in hospitals. After training, distracted residents provided the same quality handoff as those able to communicate in a quiet place.
Carlile N, Rhatigan JJ, Bates DW. BMJ Qual Saf. 2017;26:24-29.
Despite the ubiquity of smartphones, the vast majority of physicians still rely on one-way pagers for communication. This study analyzed the frequency and content of pages on an internal medicine service at a teaching hospital and compared the data to a similar study performed in 1988. Physicians received an average of 22 pages per day, of which 76% were deemed clinically relevant by independent reviewers and 82% required a response. This represented a nearly 50% increase in the volume of pages compared to 1988. Doctors on regionalized services (where patients were admitted to a common unit) received significantly fewer pages than those caring for patients on nonregionalized services, implying that regionalized services may aid face-to-face communication. As interruptions have been shown to negatively affect patient safety, the authors advocate for developing secure two-way methods of communication (such as secure text messaging) for nurses and physicians in order to improve the efficiency of communication around clinical issues.
Werner NE, Holden RJ. Appl Ergon. 2015;51:244-54.
Interruptions are a known safety hazard that occur frequently. This systematic review proposes that interruptions be considered a process with various potential consequences for multiple actors rather than single events and suggests a human factors approach to addressing interruptions.
Tubbs-Cooley HL, Pickler RH, Younger JB, et al. J Adv Nurs. 2015;71:813-24.
This study surveyed nurses in neonatal intensive care units about missed nursing care. As in other care settings, missed nursing care is significant, and reasons include interruptions, urgent patient situations, and increases in patient volume. This finding underscores the need to enhance nursing workflow to prevent errors of omission.
Nguyen C, McElroy LM, Abecassis MM, et al. Int J Med Inform. 2015;84:101-10.
Pagers have been a mainstay for urgent clinician–clinician communication for many decades. Increasingly physicians are using a variety of electronic devices, including smartphones and Web-based technologies. This systematic review identified 16 articles that studied different technologies for urgent clinician communication. Each strategy had potential advantages and pitfalls. For example, smartphones are associated with decreased transmission time compared to pagers, but they also result in more clinician interruptions. There is very little evidence linking any specific communication method with benefits for patient care. Future study could more robustly explore which forms of communication are best for clinicians and patients. A prior AHRQ WebM&M commentary describes a case of serious patient harm related to a smartphone interruption.
Estryn-Behar MR, Milanini-Magny G, Chaumon E, et al. J Patient Saf. 2014;10:29-44.
This direct observation study found that registered nurses, physicians, and nursing aides have frequent interruptions and limited time for shift-change handoffs. This finding suggests that widespread efforts to ensure adequate handoff time and minimize interruptions have not mitigated these problems in hospital settings.
Li SYW, Magrabi F, Coiera E. J Am Med Inform Assoc. 2012;19:6-12.
Interruptions pose a significant safety hazard for health care providers performing complex tasks, such as signout or medication administration. However, as prior research has pointed out, many interruptions are necessary for clinical care, making it difficult for safety professionals to develop approaches to limiting the harmful effects of interruptions. Reviewing the literature on interruptions from the psychology and informatics fields, this study identifies several key variables that influence the relationship between interruption of a task and patient harm. The authors provide several recommendations, based on human factors engineering principles, to mitigate the effect of interruptions on patient care. A case of an interruption leading to a medication error is discussed in this AHRQ WebM&M commentary.
Rivera-Rodriguez AJ, Karsh B-T. Qual Saf Health Care. 2010;19:304-312.
The majority of individual errors are due to failure to perform automatic or reflexive actions. A major risk factor for these "slips" is being interrupted or distracted while performing a task. This review examined the literature on the incidence, risk factors, and effects of interruptions in several clinical settings, ranging from outpatient clinics to the operating room. Although distractions are common and may be associated with increased risk for error, particularly if they occur during medication administration or signout, the authors point out that many interruptions may be necessary to communicate urgent clinical information. They argue for complexity theory–based research to delineate the harmful and beneficial aspects of interruptions, rather than for interventions that seek to simply eliminate interruptions. Checklists have been widely adopted as a means of preventing errors of omission, which may be precipitated by interruptions.