The PSNet Collection

COVID-19 Pandemic Impact on Healthcare Associated Conditions

Articles contained in this library reflect the impact of the pandemic on patient harm in the acute care setting.

Potentially severe incidents during interhospital transport of critically ill patients, frequently occurring but rarely reported: a prospective study.

Eiding H, Røise O, Kongsgaard UE. J Patient Saf. 2022;18(1):e315-e319.

Reporting patient safety incidents is essential to improving patient safety. This study compared the number of self-reported (to the study team) safety incidents during interhospital transport and the number of incidents submitted to the hospital’s reporting system. Nearly half of all patient transports had at least one self-reported incident; however, only 1% of incidents were reported to the hospital’s electronic reporting system.

Characteristics of critical incident reporting systems in primary care: an international survey.

Höcherl A, Lüttel D, Schütze D, et al. J Patient Saf. 2022;18(1):e85-e91.

Critical incident reporting systems (CIRS) are used to improve learning and patient safety. The aim of this study was to support future implementation of CIRS in primary care by discussing types of incidents that should be reported; who can report incidents (e.g., nurses, physicians, patients); whether reporting is mandatory or voluntary or both depending on incident severity; local versus central analysis; barriers and methods to overcome them; and motivation for reporting.

What counts as a voiceable concern in decisions about speaking out in hospitals: A qualitative study.

Dixon-Woods M, Aveling EL, Campbell A, et al. J Health Serv Res Policy. 2022;Epub Jan 3.

A key aspect of patient safety culture is the perception that all team members should speak up about safety concerns. In this study of 165 frontline and senior leader participants, deciding to report a safety event (referred to as a “voiceable concern”) is influenced by four factors: certainty that something is wrong and is an occasion for voice; system versus conduct concerns, forgivability, and normalization. Organizational culture and context effect whether an incident is considered a voiceable concern.

Medication/Drug Errors

The medication-use process is highly complex with many steps and risk points for error, and those errors are a key target for improving safety. This Library reflects a curated selection of PSNet content focused on medication and drug errors. Included resources explore understanding harms from preventable medication use, medication safety improvement strategies, and resources for design.

Patient Safety.

Dean J, Subbe C, eds. Future Healthc J. 2021;8(3):e559-e618.

Full realization of the patient voice as a resource for safety is challenging. This special section provides global perspectives examining cultural, organizational, and system-focused opportunities to fully use patient knowledge in improvement initiatives.

Learning from diagnostic errors to improve patient safety when GPs work in or alongside emergency departments: incorporating realist methodology into patient safety incident report analysis.

Cooper A, Carson-Stevens A, Cooke M, et al. BMC Emerg Med. 2021;21(1):139.

Overcrowding in the emergency department (ED) can result in increased frequency of medication errors, in-hospital cardiac arrest, and other patient safety concerns. This study examined diagnostic errors after introducing a new healthcare service model in which emergency departments are co-located with general practitioner (GP) services. Potential priority areas for improvement include appropriate triage, diagnostic test interpretation, and communication between GP and ED services.

Safety, Equity and Engagement in Maternity Services.

Newcastle upon Tyne, UK: Care Quality Commission; September 2021.

The safety of maternity care is threatened by inequity. This report analyzes a set of United Kingdom investigation reports to identify issues affecting maternity care to determine their prevalence elsewhere in the system. Problems identified include poor leadership and teamwork, as well as learning and cross-service collaboration.

Use and impact of virtual primary care on quality and safety: The public's perspectives during the COVID-19 pandemic.

Neves AL, van Dael J, O’Brien N, et al. J Telemed Telecare. 2021;Epub Dec 12.

This survey of individuals living in the United Kingdom, Sweden, Italy, and Germany identified an increased use of virtual primary care services – such as telephone or video consultation, remote triage, and secure messaging systems – since the onset of the COVID-19 pandemic. Respondents reported that virtual technologies positively impacted multiple dimensions of care quality, including timeliness, safety, patient-centeredness, and equity.

The International Forum on Quality and Safety in Healthcare Europe.

Institute for Healthcare Improvement and British Medical Journal. March 30 - April 1 2022, Gothenburg, Sweden.

This onsite conference offers an introduction to quality and safety improvement success and challenges drawing from international experiences. Course activities designed for a multidisciplinary audience supporting the theme of "Creating tomorrow today: how does quality improvement shape the “new normal” " will cover topics such as healthcare inequality, safety culture, and patient partnerships.

Next of kin involvement in regulatory investigations of adverse events that caused patient death: a process evaluation.

Wiig S, Haraldseid-Driftland C, Tvete Zachrisen R, et al. J Patient Saf. 2021;17(8):e1707-e1718.

Families and next of kin are important partners in patient safety. In two Norwegian counties, next of kin who had lost a family member due to an adverse event participated in in-person meetings with inspectors as part of the regulatory investigation. This study explored the experiences and perspectives of the next of kin (Part 1) and regulatory inspectors (Part 2) involved in this new approach to next-of-kin involvement in regulatory investigations. Despite being an emotionally challenging process, next of kin viewed participation in the regulatory investigation as a positive experience and believed that their contributions improved the investigation process.

ASK ME!-Routine measurement of patient experience with patient safety in ambulatory care: a mixed-mode survey

Stahl K, Groene O. PLoS ONE. 2021;16(12):e0259252.

Patient safety in ambulatory care is an emerging focus of measurement and improvement efforts. This cross-sectional study including patients from 22 ambulatory care practices in Germany found that nearly 3% of respondents had experienced a patient safety event during the last 12 months. The authors discuss how different approaches to voluntary reporting can influence measurement of patient experience.

Using failure mode and effects analysis to increase patient safety in cancer chemotherapy.

Weber L, Schulze I, Jaehde U. Res Social Adm Pharm. 2021;Epub Nov 18.

Chemotherapy administration errors can result in serious patient harm. Using failure mode and effects analysis (FMEA), researchers identified potential failures related to the medication process for intravenous chemotherapy. Common failures included incorrect patient information, non-standardized chemotherapy protocols, and problems related to supportive therapy.

Identifying safe care processes when GPs work in or alongside emergency departments: a realist evaluation.

Cooper A, Carson-Stevens A, Edwards M, et al. Br J Gen Pract. 2021;71(713):e931-e940.

In an effort to address increased patient demand and resulting patient safety concerns, England implemented a policy of general practitioners working in or alongside emergency departments. Thirteen hospitals using this service model were included in this study to explore care processes and patient safety concerns. Findings are grouped into three care processes: facilitating appropriate streaming decisions, supporting GPs’ clinical decision making, and improving communication between services.

The aspects of healthcare quality that are important to health professionals and patients: a qualitative study.

Hannawa AF, Wu AW, Kolyada A, et al. Patient Educ Couns. 2021;Epub Oct 30.

In this qualitative study, researchers explore physician, nurse, and patient perspectives about what features constitute “good” and “poor” care episodes. Participants highlighted the importance of quickly identifying and responding to errors and failures as one key component of good quality care.

Assessment of requests for medication-related follow-up after hospital discharge, and the relation to unplanned hospital revisits, in older patients: a multicentre retrospective chart review.

Cam H, Kempen TGH, Eriksson H, et al. BMC Geriatr. 2021;21(7):618.

Poor communication between hospital and primary care providers can lead to adverse events, such as hospital readmission. In this study of older adults who required medication-related follow-up with their primary care provider, the discharging provider only sent an adequate request for 60% of patients. Of those patients that did not have an adequate request, 14% had a related hospital revisit within 6 months.

How do patients respond to safety problems in ambulatory care? Results of a retrospective cross-sectional telephone survey.

Seufert S, de Cruppé W, Assheuer M, et al. BMJ Open. 2021;11(11):e052973.

Patient reports of patient safety incidents are one method to detect safety hazards. This telephone survey of German citizens found that patients frequently report patient safety incidents back to their general practitioner or specialist and these incidents can lead to loss of trust in the physician.

Reducing failure to rescue rates in a paediatric in-patient setting: a 9-year quality improvement study.

McHale S, Marufu TC, Manning JC, et al. Nurs Crit Care. 2021;Epub Oct 20.

Failure to identify and prevent clinical deterioration can reflect the quality and effectiveness of care. This study used routinely collected emergency event data to identify failure to rescue events at one tertiary children’s hospital. Over a nine-year period, 520 emergency events were identified; 25% were cardiac arrest events and 60% occurred among patients who had been admitted for more than 48 hours. Over the nine-year period, failure to rescue events decreased from 23.6% to 2.5%.

SECUre: a multicentre survey of the safety of emergency care in UK emergency departments.

Flowerdew L, Tipping M. Emerg Med J. 2021;38(10):769-775.

This study sought to validate an emergency department (ED) safety questionnaire developed in the United States, and adapted for use in the UK. The survey was validated by 33 patient safety leads and used in a multi-center survey. Analysis highlighted risks and positive factors (e.g., positive safety culture) present in surveyed EDs.

Artificial intelligence for identifying the prevention of medication incidents causing serious or moderate harm: an analysis using incident reporters' views.

Härkänen M, Haatainen K, Vehviläinen-Julkunen K, et al. Int J Environ Res Public Health. 2021;18(17):9206.

Building on previous research on the use of text mining related to medication administration error incidents, researchers in this study found that artificial intelligence can be used to accurately classify the free text of medication incident reports causing serious or moderate harm, to identify target risk management areas.

All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Provide Feedback Anonymously

Submit Your Case

Continue as a Guest

Continue Logged In

Submit Your Case

Continue as a Guest

Already have a PSNet

Account?

New Users