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.

Search All Content

Clear all filter(s)

Displaying 1 - 20 of 1526 Results

Identifying and mapping measures of medication safety during transfer of care in a digital era: a scoping literature review.

Save to Library

Leon C, Hogan H, Jani YH. BMJ Qual Saf. 2023;Epub Nov 3.

Errors associated with high-risk medications (HRM) like insulin and anticoagulants carry a greater risk for harm. The purpose of this scoping review was to identify measures evaluating the safety of HRM during transitions of care. Measures were mapped to frameworks (e.g., Donabedian) and whether measures were reactive, proactive, or real-time. The authors describe ways technology can improve how the measures are implemented.

When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)!

Save to Library

WebM&M Case November 30, 2023

A 67-year-old man with well-controlled type 2 diabetes mellitus underwent elective cardiac resynchronization and defibrillator device (CRT-D) implantation. The procedure was successful and he was discharged the next day with instructions to resume his prior medications, including empagliflozin. He presented to the emergency department the following day where he was diagnosed with euglycemic diabetic ketoacidosis (eDKA) and he was transferred to the intensive care unit (ICU) for insulin infusion.

The Risks of a Malpositioned Gastrostomy Tube and Poor Communication

Save to Library

WebM&M Case November 29, 2023

This case describes a 55-year-old woman who sustained critical injuries after a motor vehicle crash and had a lengthy hospitalization. On hospital day 30, a surgeon placed a percutaneous endoscopic gastrostomy (PEG) tube in the intensive care unit (ICU) after computed tomography (CT) scan showed no interposed bowel between the stomach and the anterior abdominal wall. After the uncomplicated PEG placement, the surgeon cleared the patient’s team to advance tube feeds as tolerated.

The complexities of communication at hospital discharge of older patients: a qualitative study of healthcare professionals' views.

Save to Library

Cam H, Wennlöf B, Gillespie U, et al. BMC Health Serv Res. 2023;23:1211.

When patients are discharged from the hospital, they (and their informal caregivers) are given copious amounts of information that must also be communicated to their primary care provider. This qualitative study of primary care and hospital physicians, nurses, and pharmacists highlights several barriers to complete and effective communication between levels of care, particularly regarding geriatric medication safety. Barriers include the large number of complex patients and incongruent expectations of responsibility of primary and hospital providers. Support systems, such as electronic health records, can both enable and hinder communication.

Prevented harm and cost avoidance with pharmacist intervention while utilizing a discharge medication reconciliation tool.

Save to Library

Hoffman AM, Walls JL, Prusch A, et al. Am J Health Syst Pharm. 2023;Epub Oct 9.

Hospitals must balance costs associated with pharmacist medication reconciliation (e.g., salary) with prevented harm and cost avoidance (e.g., unreimbursed expenses resulting from medication error). This study found an estimate cost avoidance of $47,000 - $231,000 during one month in one hospital. The highest-risk, highest-cost classes were insulin, antithrombotics, and opioids. In resource-limited environments, focusing on the highest-cost classes could avoid significant cost and patient harm.

Deficiencies in Quality Management Processes and Delays in the Communication of Test Results and Follow-Up Care at the Phoenix VA Health Care System in Arizona.

Save to Library

Washington DC; VA Office of the Inspector General; October 31, 2023; Report no. 22-03599-07.

Disclosure failures detract from learning, appropriate incident examination, and safe care delivery. This report examined factors contributing to poor disclosure practices associated with the care of three patients. Lack of report submission, uninitiated root cause analysis, and inadequate documentation were process weaknesses highlighted by the review.

Advancing Diagnostic Excellence for Maternal Health Care: Proceedings of a Workshop–in Brief.

Save to Library

National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2023. ISBN: 9780309711937.

Maternal health care is rapidly emerging as a high-risk service that is vulnerable to communication, equity, and diagnostic challenges. This report examines the role of disparities in care across the maternal care continuum and strategies to drive diagnostic improvement such as care bundles, midwives, and health information technology. This publication is from a series of programs and resultant publications on improving diagnostic excellence.

Facilitators and barriers to the implementation of surgical safety checklist (SSC): an integrative review.

Save to Library

Lim PJH, Chen L, Siow S, et al. Int J Qual Health Care. 2023;35:mzad086.

Surgical safety checklists (SCC) are utilized around the world, but checklist completion at the operating room level remains inconsistent. This review summarizes facilitators and barriers to completion. Resistance or endorsement at the individual surgeon level remains a significant factor in SSC completion. Early inclusion of frontline staff in evaluation and implementation supported increased use.

Network of Patient Safety Databases Chartbook.

Save to Library

Rockville, MD: Agency for Healthcare Research and Quality; September 2023. AHRQ Publication no. 23-0082.

The sharing of data is a core element of a learning health system. AHRQ has released the Network of Patient Safety Databases (NPSD) Chartbook 2023, which offers an overview of nonidentifiable, aggregated patient safety event and near-miss information, voluntarily reported by AHRQ-listed Patient Safety Organizations across the country between June 2014 and December 2022. The chartbook outlines the extent of harm reported, distribution of patient safety events, near misses, and unsafe conditions.

Identifying barriers and enablers for a robust independent second check of medication in adult intensive care.

Save to Library

Milic V, Cameron L, Jones C. Br J Nurs. 2023;32:840-848.

Double checking of medication administration one strategy meant to reduce medication errors. In this study, 29 critical care nurses took part in a focus group exploring the barriers to double-checking during medication administration. Participants discussed several challenges, such as patient location (particularly for patients in isolation due to infection control measure), health IT limitations, and unclear roles and responsibilities.

Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose.

Save to Library

WebM&M Case October 31, 2023

A 2-year-old girl presented to the emergency department (ED) with joint swelling and rash following an upper respiratory infection. After receiving treatment and being discharged with a diagnosis of allergic urticaria, she returned the following day with worsening symptoms. Suspecting an allergic reaction to amoxicillin, the ED team prepared to administer methylprednisolone. However, the ED intake technician erroneously switched the patient’s height and weight in the electronic health record (EHR), resulting in an excessive dose being ordered and dispensed.

Delay in Malignancy Diagnosis Reflects Systemic Failures.

Save to Library

WebM&M Case October 31, 2023

A 32-year-old man presented to the hospital with a comminuted midshaft femoral fracture after a bicycle accident. Imaging suggested the fracture was pathologic and an open biopsy specimen was submitted to pathology for intraoperative consultation.

Medication safety events after acute myocardial infarction among veterans treated at VA versus non-VA hospitals.

Save to Library

Weeda ER, Ward R, Gebregziabher M, et al. Med Care. 2023;Epub Oct 4.

Fragmentation of care between inpatient and outpatient settings can lead to poor patient outcomes. Based on a cohort of veterans ages 65 years or older who had a myocardial infarction, this study examined the use of outpatient medications for secondary prevention (e.g., beta blockers, statins) in the preceding 30 days among patients treated at Veterans Health Administration (VA) versus non-VA hospitals. The researchers found that medication omissions, duplications and delays in prescribing of secondary prevention medications were more common among patients treated at non-VA hospitals.

The nature, causes, and clinical impact of errors in the clinical laboratory testing process leading to diagnostic error: a voluntary incident report analysis.

Save to Library

van Moll C, Egberts TCG, Wagner C, et al. J Patient Saf. 2023;19:573-579.

Diagnostic testing errors can contribute to delays in diagnosis and to serious patient harm. Researchers analyzed 327 voluntary incident reports from one medical center in the Netherlands and found that diagnostic testing errors most commonly occurred during the pre-analytic phase (77%), and were predominantly caused by human factors (59%). The researchers found that these diagnostic testing errors contributed to a potential diagnostic error in 60% of cases.

Curated Libraries

Patient as a Team Member in Clinical Care

October 23, 2023

This curated library highlights concepts associated with the patient as a partner for safety at the team level directly connected to personal clinical encounters.

Adverse drug events caused by three high-risk drug-drug interactions in patients admitted to intensive care units: a multicentre retrospective observational study.

Save to Library

Klopotowska JE, Leopold J‐H, Bakker T, et al. Br J Clin Pharmacol. 2023;Epub Aug 11.

Identifying and preventing drug-drug interactions (DDI) is critical to patient safety, but the usual method of detecting DDI and other errors - manual chart review - is resource intensive. This study describes the use of an e-trigger to pre-select charts for review that are more likely to include one of three DDIs, thus reducing the overall number of charts needing review. Two of the DDI e-triggers had high positive predictive values (0.76 and 0.57), demonstrating that e-triggers can be a useful method to pre-selecting charts for manual review.

Pharmacy-led medication reconciliation is best practice.

Save to Library

Tanski MC. Pharmacy Times Health Systems edition. September 2023;12(5):34-35.

Medication reconciliation should be completed at admission, discharge, and during transitions of care. This article describes the impacts of pharmacist involvement, including lower hospital readmissions and post-discharge adverse events.

Inpatient EHR user experience and hospital EHR safety performance.

Save to Library

Classen DC, Longhurst CA, Davis T, et al. JAMA Netw Open. 2023;6:e2333152.

Electronic health records (EHR) with computerized provider order entry (CPOE) help prevent many types of medication errors but poor user design can hinder these benefits. Using scores from the National Quality Forum Leapfrog Health IT Safety Measure and the ARCH Collaborative EHR User experience survey, this study compares safety scores and physician perceptions of usability. Results indicate a positive association between safety performance and user experience, affirming the importance of user-centered design.

A virtual breakthrough series collaborative to support deprescribing interventions across Veterans Affairs healthcare settings.

Save to Library

Phillips KK, Mecca MC, Baim‐Lance AM, et al. J Am Geriatr Soc. 2023;71:2935-2945.

Polypharmacy is a common patient safety concern among veterans. In this study, 21 Veterans Health Administration (VA) sites developed their own deprescribing protocols and participated in a virtual deprescribing collaborative. Sites employed decision support tools, such as the VA VIONE tool, and other strategies, such as individualized medication review, to encourage deprescribing and reduce polypharmacy among its patients.

Scaling up a diagnostic pause at the ICU-to-ward transition: an exploration of barriers and facilitators to implementation of the ICU-PAUSE handoff tool.

Save to Library

Cornell EG, Harris E, McCune E, et al. Diagnosis (Berl). 2023;10:417-423.

Structured handoffs can improve the quality of patient information passed from one care team to another. This article describes intensivists' perspectives on a potential handoff tool (ICU-PAUSE) for handoff from the intensive care unit (ICU) to medical ward. They described the usefulness of a structured clinical note, especially regarding pending tests and the status of high-risk medications. Several barriers were also discussed, such as the frequent training required for residents who rotate in and out of the ICU and potential duplication of the daily chart note.

The PSNet Collection: All Content

Search All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

The PSNet Collection: All Content

Search All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site