Skip to main content

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

Search Tips
Filter By Author(s)
Advanced Filtering Mode
Date Ranges
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Additional Filters
Approach to Improving Safety
Displaying 1 - 20 of 30 Results
Shafi S, Collinsworth AW, Copeland LA, et al. JAMA Surg. 2018;153:757-763.
Opioids are known to be high-risk medications. This secondary data analysis of more than 100,000 patients undergoing in-hospital surgical procedures at 21 hospitals found that about 10% experienced an opioid-related adverse drug event during their admission. Patients receiving higher dose and longer duration of opioids were more likely to experience adverse events. Patients who experienced an opioid-related adverse drug event had longer hospital stays, greater inpatient mortality risk, and a higher rate of readmissions compared to those who did not experience problems with opioid medications. The authors call for reducing opioid use in acute care, postoperative settings in order to improve patient safety. A previous WebM&M commentary emphasized the importance of stratifying risk for patients initiated or maintained on chronic opioid therapy to prevent misuse.
Axeen S, Seabury SA, Menchine M. Ann Emerg Med. 2018;71:659-667.e3.
As deaths and overdoses related to opioid use have increased, physician prescribing behavior is under greater scrutiny. Prior research has shown significant variation in opioid prescribing among emergency medicine physicians, but the degree to which emergency department prescribing contributes to overall opioid prescribing remains unknown. This retrospective study used data from the Medical Expenditure Panel Survey from 1996 to 2012 and found that the quantity of opioids prescribed increased by 471% during the study period. While the percentage of opioids prescribed in the ambulatory setting increased from 71% in 1996 to 83% in 2012, the percentage of opioids prescribed in the emergency department decreased from 7.4% in 1996 to 4.4% in 2012. Based on these findings, the authors suggest that interventions designed to reduce opioid prescribing should target the outpatient setting rather than the emergency department. A past PSNet perspective discussed opioid medications and associated patient safety risks.
Harbaugh CM, Lee JS, Hu HM, et al. Pediatrics. 2018;141:e20172439.
Opioid misuse is an urgent patient safety issue. Research has found that a significant proportion of adults prescribed opioids in the short term remain on opioid medications chronically, but less is known about postsurgical opioid use among pediatric patients. This study analyzed a large, commercial health care claims database to determine whether children and adolescents prescribed opioids following surgery were more likely to be prescribed opioids 3 to 6 months later, compared to children who did not undergo surgery. Researchers found that postoperative opioid use was associated with persistent opioid use. A related editorial raises questions about the breadth of procedures included and calls for development and implementation of evidence-based pediatric pain management strategies that address the risk for persistent opioid use and misuse.
Ravi B, Pincus D, Wasserstein D, et al. JAMA Intern Med. 2018;178:75-83.
Overlapping surgery is the practice of surgeons scheduling distinct procedures on different patients concurrently. This practice has raised safety concerns. This large population-based retrospective study examined outcomes for nonoverlapping versus overlapping hip surgeries across Ontario, Canada. After adjustment for factors known to predict surgical outcomes, such as hospital and surgeon case volume and the patient's overall health, researchers found an association between increasing duration of surgical overlap and higher risk of complications. These results contrast with a recent single-center study that found no safety differences between overlapping and nonoverlapping neurosurgeries. An accompanying editorial acknowledges the mixed results of safety studies for overlapping surgeries and calls for large, multicenter, prospective studies across a range of surgical procedures with long-term follow-up.
Chaudhary MA, Schoenfeld AJ, Harlow AF, et al. JAMA Surg. 2017;152:930-936.
The epidemic of deaths associated with opioid medications has spurred research examining clinicians' prescribing patterns. Recent studies have shown that opioids are frequently prescribed in situations where there is little evidence of their benefit—such as after dental procedures—and that there is considerable variation in prescribing rates between providers. However, the true incidence of inappropriate opioid prescribing has not yet been defined. This retrospective study of patients who had sustained traumatic injuries examined the relationship between injury severity and opioid prescribing. Investigators found that patients with more severe injuries were more likely to be prescribed opioids, indicating that opioid prescribing in this context was likely appropriate in most cases. The study and accompanying editorial emphasize the importance of targeted efforts to reduce inappropriate opioid prescribing, focusing primarily on reducing opioid use for chronic noncancer pain (where there is no evidence opioids are beneficial) while not denying opioids to those in acute pain from trauma or other reasons.
Cooper WO, Guillamondegui O, Hines J, et al. JAMA Surg. 2017;152:522-529.
Most patient safety problems can be ascribed to underlying systems failures, but issues with individual clinicians play a role as well. Prior studies have shown that a small proportion of physicians account for a disproportionate share of patient complaints and malpractice lawsuits. This retrospective cohort study used data from the Patient Advocacy Reporting System (which collects unsolicited patient concerns) and the National Surgical Quality Improvement Program to examine the association between patient complaints and surgical adverse events. The investigators found that patients of surgeons who had received unsolicited patient concerns via the reporting system were at increased risk of postoperative complications and hospital readmission after surgery. Although the absolute increase in complication rates was relatively small across all surgeons, surgeons in the highest quartile of unsolicited observations had an approximately 14% higher risk of complications compared to surgeons in the lowest quartile. This study extends upon prior research by demonstrating an association between patient concerns about individual clinicians and clinical adverse events, and it strengthens the argument for using data on patient concerns to identify and address problem clinicians before patients are harmed.
Obermeyer Z, Cohn B, Wilson M, et al. BMJ. 2017;356:j239.
The emergency department is considered a high-risk setting for diagnostic errors. This analysis of Medicare claims data found that a significant number of adults age 65–89 died within a week of visiting and being discharged from an emergency department, even when no life-limiting illness was noted. Hospitals that admit a lower proportion of emergency department patients to the inpatient setting had a higher mortality rate among discharged patients, even after adjusting for patient characteristics. Consistent with prior studies relating patient outcomes to volume, higher-volume emergency departments had lower 7-day mortality among discharged patients. These results suggest that emergency department discharges may represent missed diagnoses. A WebM&M commentary discussed an incident involving a patient who died after being discharged from the emergency department.
Hyder JA, Hanson KT, Storlie CB, et al. Ann Surg. 2017;265:639-644.
Overlapping surgery refers to when two procedures are performed concurrently, but important portions occur at different times. Experts have raised concerns about the safety of scheduling coincident procedures. This study compared overlapping surgeries with nonoverlapping surgeries of the same type at a single referral center. After adjusting for surgeon and patient characteristics, investigators found no differences in inpatient mortality or length of stay. They performed an analogous analysis in the National Surgical Quality Improvement Program registry medical record data, which resulted in similar findings. Although these results should allay concerns about concurrent surgeries, the authors caution that further studies at multiple centers are needed to ensure that overlapping procedure practices do not carry excess risk to patients.
Geller AI, Shehab N, Weidle NJ, et al. N Engl J Med. 2015;373:1531-40.
Dietary supplements can cause harm, especially in combination with prescribed medication, and their use is increasing. This report from an established surveillance system sampled emergency department visits related to dietary supplements. The results suggest that adverse events related to dietary supplements cause 23,000 emergency department visits per year in the United States. Ingestions by unsupervised children accounted for nearly a quarter of the visits. Other common events included palpitations, chest pain, or tachycardia related to weight loss or energy supplements. The authors note that there is no legal requirement for supplement manufacturers to identify potential adverse effects on the products themselves, and they encourage clinicians to educate patients about potential adverse reactions.
Nanji KC, Patel A, Shaikh S, et al. Anesthesiology. 2016;124:25-34.
Medication errors in the hospital have been studied, quantified, and systematically evaluated for potential solutions. A notable exception is the perioperative setting, where medications given by anesthesiologists often bypass standard safety checks. This study is the largest prospective observational study of anesthesia-related medication events available to date. At least one medication error or adverse drug event occurred in nearly half of the 277 operations observed. Approximately 1 in 20 perioperative medication administrations resulted in a medication error or adverse drug event; 80% of these errors were deemed preventable. None of the errors resulted in death, but 2% were considered life-threatening. There were no differences in event rates among resident physicians, nurse anesthetists, and staff anesthesiologists. The study took place at an academic hospital with substantial local expertise in medication safety, where operating rooms already used a barcode-assisted syringe labeling system. An accompanying editorial suggests that medication error rates may therefore be even higher in other settings and community hospitals.
Govindarajan A, Urbach DR, Kumar M, et al. N Engl J Med. 2015;373:845-53.
The link between lack of sleep and subsequent medical errors served as an impetus for physician duty-hours reform. In trainee physicians, sleep loss is associated with attentional failures, but little is known about the relationship between attending physician performance and sleep loss. This retrospective cohort study examined outcomes of elective surgical procedures among attending surgeons who had worked after midnight on the previous night versus those who had not. The investigators found no differences in mortality, complications, or readmissions between procedures performed by surgeons with sleep loss compared to those without sleep loss, mirroring results of an earlier simulation study. This may be due to greater technical skill among attending surgeons, or the ability to cancel or postpone elective procedures as needed at times of fatigue. This study included many institutions, physicians, and procedure types, suggesting that short-term sleep deprivation might not be a high-yield safety target for attending surgeons.
Haut ER, Lau BD, Kraus PS, et al. JAMA Surg. 2015;150:912-5.
Prevention of hospital-acquired venous thromboembolism (VTE) is a strongly recommended patient safety practice. This retrospective review of hospital-acquired VTE at one tertiary care hospital found that many patients who developed VTE while hospitalized were prescribed appropriate prophylaxis but did not receive all of the prescribed doses. The authors point out that since current quality metrics measure only prescription of VTE prophylaxis and not actual administration, they may overestimate hospital performance on this safety issue. Moreover, nearly half of the patients with VTE had received prophylaxis that is currently considered optimal, an important finding since VTE is often referred to as a "preventable adverse event."
Thiels CA, Lal TM, Nienow JM, et al. Surgery. 2015;158:515-21.
Never events are devastating and preventable, and health care organizations are under increasing pressure to eliminate them completely. In this study, investigators evaluated all procedural never events using a validated human factors analysis method. They uncovered multiple underlying causes for each event. Cognitive failures were identified in about half the events. Preconditions, including environmental and technologic factors, were common contributors to events. Consistent with prior studies, the authors recommend enhancing communication among team members to augment safety. These results demonstrate the need to develop individual cognitive training interventions as well as systems approaches to address never events.
Osborne NH, Nicholas LH, Ryan AM, et al. JAMA. 2015;313:496-504.
This large study used 9 years of national fee-for-service Medicare data to examine differences in surgical outcomes between hospitals participating in the National Surgical Quality Improvement Program (NSQIP) and nonparticipating hospitals. There was no statistically significant difference in the rate of improvement for any of the measured outcomes—risk-adjusted 30-day mortality, serious complications, reoperation, or 30-day readmissions—at 1, 2, or 3 years after enrollment in NSQIP versus well-matched controls. Notably, over 6 years there has been a trend toward reductions in mortality, serious complications, and readmissions across hospitals, regardless of NSQIP participation. The results of this study strengthen those of the study by Etzioni and colleagues in the same issue of the Journal of the American Medical Association. In an accompanying editorial, Dr. Donald Berwick states, "it is implausible to conclude that knowing results is not useful—perhaps essential—for systematic improvement of outcomes," but that hospitals must realize measurement alone is insufficient.
Merkow RP, Ju MH, Chung JW, et al. JAMA. 2015;313:483-495.
Hospital readmissions have received intensive focus lately, largely compelled by Medicare's expanded financial penalties for excessive readmission rates. This study reviewed 30-day readmissions following surgery at hospitals enrolled in the National Surgical Quality Improvement Program. Nearly half a million operations were included, with an overall readmission rate of 5.7%. Following lower extremity vascular bypass, approximately 1 in 7 patients were readmitted. Surgical site infections accounted for the largest proportion of overall readmissions. It is notable that only 2% of patients were readmitted for the same complication that prompted their index admission, further confirming that surgical readmissions are overwhelmingly due to new complications arising from the procedure. In an accompanying editorial, Dr. Lucian Leape notes that analyses of these surgical complications can serve as "treasures" for providing important lessons for improvement, and he calls for a 50% reduction in surgical complication rates in the near term.
Johnston MJ, Arora S, King D, et al. Surgery. 2014;155:989-94.
This interview study examined escalation of care, the process by which a patient's deteriorating clinical status is recognized and acted upon, among surgical patients. Attending surgeons, trainees, intensivists, and rapid response team members believe that protocols for escalation of care lack clarity and that there is a dearth of supervision from senior clinicians. Similar to studies of handoffs, direct conversation—either in person or via mobile phone—was deemed preferable to hospital paging systems. Participants identified communication training, explicit and clear protocols, and increased supervision as key to improving the care of deteriorating surgical patients. Accompanying editorials highlight the importance of communication and the need for a safety culture that supports multidisciplinary teams.
Carayon P, Wetterneck TB, Cartmill R, et al. BMJ Qual Saf. 2014;23:56-65.
As the patient safety field matures, there is increasing recognition of the need to incorporate human factors engineering methods into analyzing errors and developing solutions. These methods were used to investigate the types and frequency of medication errors in two intensive care units. Although existing medication safety interventions have mainly targeted errors at individual stages of the medication management process (e.g., computerized provider order entry [CPOE] to prevent prescribing errors), this study found that in many cases, errors occurred in an interdependent fashion at multiple stages of the process. For example, incorrect transcription of an order could then lead to a medication administration error. While CPOE is likely a solution for a significant proportion of errors, this study's results indicate a need for closed-loop systems that can minimize the risk of all types of medication errors.
Birkmeyer JD, Finks JF, O'Reilly A, et al. N Engl J Med. 2013;369:1434-1442.
Prior research has shown that surgical outcomes differ greatly by surgeon and facility, and a national program focuses on reducing this variability. This groundbreaking study has profound implications for improving the safety of surgery. At least 10 independent surgeon-reviewers examined video-recordings of 20 bariatric surgeons performing a laparoscopic procedure and rated the surgeons' skills, with a higher score representing better technical skills. Surgeons rated in the lowest quartile of surgical skill had more surgical complications, longer surgical times, and higher mortality within 30 days of the surgery than those in the highest quartile of surgical skill. This study is the first to link practicing surgeons' directly observed technical skills to surgical safety outcomes. It underscores the need to broaden surgical improvement efforts beyond the use of systems approaches, such as teamwork and surgical checklists, and suggests incorporating technical skills assessment into programs that aim to either measure or enhance the quality and safety of care.
Eappen S, Lane BH, Rosenberg B, et al. JAMA. 2013;309:1599-606.
The business case for patient safety relies on the assumption that adverse events are financially harmful to hospitals over the long term, so up-front investment in safety improvement will eventually result in savings. However, this study cogently demonstrates that—at least for the specific case of surgical complications—hospitals actually profit when patients experience adverse events. Analysis of more than 30,000 surgical procedures revealed that hospitals received significantly greater net reimbursement for patients who experienced complications compared with those who had no complications. This disparity was particularly evident for patients with private insurance, although it was present to a lesser extent for patients with Medicare. This counterintuitive finding vividly demonstrates that, despite efforts such as the Centers for Medicare and Medicaid Services' policy of not paying for errors, payment incentives are not aligned to the extent that would truly encourage innovative approaches to improving safety. As the noted health economist Dr. Uwe Reinhart points out in his accompanying editorial, the findings of this study arise directly from a payment system that rewards providers for the volume rather than the quality of service provided.
Budnitz DS, Lovegrove MC, Shehab N, et al. New Engl J Med. 2011;365:2002-2012.
Partnership for Patients set an ambitious goal to reduce preventable readmissions by 20% in 2013. Adverse drug events contribute significantly to undesired outcomes and provide an ongoing area for prevention strategies. This study used a national surveillance database and examined nearly 100,000 emergency hospitalizations attributed to adverse drug events in elderly patients between 2007 and 2009. Investigators found that nearly half the hospitalizations were in adults older than 80 years and two-thirds were due to unintentional overdoses. The most common medications implicated were warfarin, insulin, oral antiplatelet agents, and oral hypoglycemic agents. The authors suggest that targeted strategies to minimize risk associated with these high-risk medications may reduce preventable hospitalizations in older adults.