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 362 Results

Overlapping surgery in orthopaedics: a review of efficacy, surgical costs, surgical outcomes, and patient safety.

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Ahmed M, Suhrawardy A, Olszewski A, et al. J Am Acad Orthop Surg. 2023;Epub Sep 19.

Overlapping surgeries, where one attending surgeon supervises two surgeries with noncritical portions occurring simultaneously, are generally considered as safe as non-overlapping surgeries. This review identified 11 studies into safety outcomes of overlapping orthopedic surgeries involving 34,494 overlapping surgeries. Consistent with prior research, although overlapping surgeries tended to have increased surgical times, short-term outcomes were no different than non-overlapping; one study showed increased risk for adverse events at one year. The authors suggest future research into overlapping robotic-assisted surgeries.

Failure to rescue as a patient safety indicator for neurosurgical patients: are we there yet?

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Roy JM, Rumalla K, Skandalakis GP, et al. Neurosurg Rev. 2023;46:227.

Failure to rescue (FTR) quality metrics measure the ability of healthcare teams and hospitals to prevent mortality following a major complication. This systematic review included 12 studies and examined how FTR has been used in neurosurgical populations. The authors discuss several modifications to existing FTR definitions to better suit neurosurgical patients, such as incorporating measures of baseline frailty.

Cognitive bias during clinical decision-making and its influence on patient outcomes in the emergency department: a scoping review.

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Jala S, Fry M, Elliott R. J Clin Nurs. 2023;32:7076-7085.

Cognitive biases can impact the type of care a patient receives and their subsequent outcomes, particularly in the emergency department which operates under time and resource constraints. This review identified 18 studies on cognitive biases in emergency physicians and nurses. Most studies focused on implicit bias and on physicians. Of the five studies focused solely on nurses, all assessed bias in emergency department triage.

Associations between hospitalist shift busyness, diagnostic confidence, and resource utilization: a pilot study.

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Gupta AB, Greene MT, Fowler KE, et al. J Patient Saf. 2023;19:447-452.

As high workload and interruptions are known contributors to diagnostic errors, significant research has been conducted to understand and ameliorate the impact of these factors. This study examined the association between hospitalist busyness (i.e., number of admissions and pages), resource utilization, number of differential diagnoses, and the hospitalist's diagnostic confidence and subjective awareness. Increasing levels of busyness were associated with hospitalists reporting it was "difficult to focus on what is happening in the present" but had no effect on diagnostic confidence.

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.

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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.

Pediatric Diagnostic Safety: State of the Science and Future Directions.

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Grubenhoff JA, Cifra CL, Marshall T, et al. Rockville, MD: Agency for Healthcare Research and Quality; September 2023. AHRQ Publication No. 23-0040-5-EF.

Unique challenges accompany efforts to study and reduce diagnostic error in children. This issue brief discusses addressing obstacles associated with testing and care access limitations that affect diagnosis across a variety of pediatric care environments. It also provides recommendations for building capacity to advance pediatric diagnostic safety. This issue brief is part of a series on diagnostic safety.

Hiding in plain sight: inconvenient facts for patient safety in non-24/7 theatre on-site staffed obstetric units.

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McGurgan P. Aust N Z J Obstet Gynaecol. 2023;63:606-611.

Individual-, team-, and systems-based factors can affect safety during childbirth. This article discusses several patient safety threats that can hinder the safety of vaginal birth after cesarean (VAC) deliveries in high population density areas, including staffing and resource limitations, cultural and human factors, and patient communication.

A multi-facetted patient safety resource--a qualitative interview study on hospital managers' perception of the nurse-led Rapid Response Team.

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Axelsen MS, Baumgarten M, Egholm CL, et al. J Adv Nurs. 2023;Epub Jun 30.

Rapid response teams (RRT) are activated, typically by nurses, when a patient demonstrates signs of imminent clinical deterioration, in order to prevent death or transfer to the intensive care unit (ICU). This study asks ICU managers about their perceptions of RRT beyond the stated goal of preventing patient deterioration. They describe the RRT as providing valuable education for new nurses and physicians and enhancing cohesion between the ICU and other wards. However, nurse managers stated they wanted more data and feedback from executive leadership.

Incidence and severity of medication reconciliation discrepancies in trauma patients.

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Dunbar EG, Massey AC, Lee YL, et al. Am Surg. 2023;89:3272-3274.

Medication reconciliation is an important care process anytime a patient transitions from one care setting to another, including emergency department to hospital admission. This study sought to determine the incidence of completed medication reconciliation for admitted trauma patients and the number of identified discrepancies. Of the 89 patients included in the study, more than a quarter did not receive an admission medication reconciliation (AMR), and of those with an AMR, 48% had at least one unintended discrepancy, indicating the importance of completing medication reconciliation for all admitted trauma patients.

Maternal Health of Women and Girls of African Descent in the Americas.

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New York, NY: United Nations Population Fund; July 2023.

Black women are vulnerable to unsafe health care. This report examined maternal and reproductive health care for Black women in nine countries across the Americas. The analysis found poor data collection, indifferent policies, and systemic racism and sexism as factors contributing to disparities in care for this patient population.

Medication reconciliation for patients after their discharge from intensive care unit to the hospital ward.

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Pradeda AM, Pérez MSA, Oliveira CF, et al. Farm Hosp. 2023;47:121-126.

Medication reconciliation is used when a patient moves from one level or location of care to another, to ensure they are receiving the appropriate medications. This retrospective study reviewed completed medication reconciliations of adult patients transferring from the intensive care unit to the ward. Nearly one in five had an error requiring physician changes to the order. Of those errors, 19% were high-alert medications, most notably low-molecular-weight heparin.

Patient perceptions and experiences with medication-related activities in the emergency department: a qualitative study.

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Zahl-Holmstad B, Garcia BH, Johnsgård T, et al. BMJ Open Qual. 2023;12:e002239.

Designated emergency department (ED) pharmacists are increasingly used to improve the quality of medication administration in the ED. This qualitative study explored patient perceptions of medication safety before and during an ED pharmacist-led intervention (including medication reconciliation and medication review) in collaboration with ED physicians. Participants underscored the importance of trust and responsibility but noted that it was not important who carried out these medication-related tasks, but rather that the participant received the help they needed.

Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture.

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WebM&M Case June 28, 2023

A 56-year-old man was admitted to the hospital and required mechanical ventilation due to COVID-19-related pneumonia and acute respiratory failure. The care team performed a tracheostomy percutaneously at the bedside with some difficulty. The tracheostomy tube was secured, inspected via bronchoscopy, and properly sutured. During the next few days, the respiratory therapist noticed a leak that required additional inflation of the cuff to maintain an adequate seal.

The AHRQ Report on Diagnostic Errors in the Emergency Department: the wrong answer to the wrong question.

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Kelen GD, Kaji AH, Schreyer KE, et al. Ann Emerg Med. 2023;82:336-340.

In December 2022, AHRQ released Diagnostic Errors in the Emergency Department: a Systematic Review which received extensive coverage in both academic publications and the national media. This peer-reviewed commentary asserts emergency department (ED) overcrowding is a greater safety risk than misdiagnosis, and errors are more frequently systemic rather than cognitive.

Advance Alert Monitor Program: An Automated Early Warning System for Adults At Risk for In-Hospital Clinical Deterioration

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Patient Safety Innovation June 14, 2023

To address a well-documented hospital adverse outcome (in-hospital patient clinical deterioration), Kaiser Permanente Northern California (KPNC) developed and implemented the Advance Alert Monitor (AAM) program. Using predictive analytics, the team developed a model to alert clinicians up to 12 hours prior to a patient’s likely deterioration. This early detection allowed clinicians to devise and implement a care plan to prevent deterioration of the patient’s condition and/or align the care plan with the goals of the patient.

The One That Got Away—Elopement of a Suicidal Patient in the Emergency Department.

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WebM&M Case June 14, 2023

A 25-year-old female was sent by ambulance to the emergency department (ED) by a mental health clinic for suicidal ideation. Upon arrival to the ED, she was evaluated by the triage nurse and determined to be awake, alert, calm, and cooperative and she denied current suicidal thoughts. The ED was extremely busy, and the patient was placed on a gurney with a Posey restraint in the hallway next to the triage station awaiting psychiatric social work assessment. Approximately 40 minutes later, the triage nurse noticed that the patient was missing from the gurney.

Prevalence and characteristics of diagnostic error in pediatric critical care: a multicenter study.

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Cifra CL, Custer JW, Smith CM, et al. Crit Care Med. 2023;51:1492-1501.

Diagnostic errors remain a major healthcare concern. This study was a retrospective record review of 882 pediatric intensive care unit (PICU) patients to identify diagnostic errors using the Revised Safer Dx tool. Diagnostic errors were found in 13 (1.5%) patients, most commonly associated with atypical presentation and diagnostic uncertainty at admission.

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

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Patient Safety Innovation May 31, 2023

Seeking a sustainable process to enhance their hospitals’ response to sepsis, a multidisciplinary team at WellSpan Health oversaw the development and implementation of a system that uses customized electronic health record (EHR) alert settings and a team of remote nurses to help frontline staff identify and respond to patients showing signs of sepsis. When the remote nurses, or Central Alerts Team (CAT), receive an alert, they assess the patient’s information and collaborate with the clinical care team to recommend a response.

Types of diagnostic errors reported by paediatric emergency providers in a global paediatric emergency care research network.

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Mahajan P, Grubenhoff JA, Cranford J, et al. BMJ Open Qual. 2023;12:e002062.

Missed diagnostic opportunities often involve multiple process breakdowns and can lead to serious avoidable patient harm. Based on a web-based survey of 1,594 emergency medicine physicians, missed diagnostic opportunities most frequently occur in children who present to the emergency department with undifferentiated symptoms (e.g., abdominal pain, fever, vomiting) and often involve issues related to the patient/parent-provider interaction, such as misinterpreting patient history or inadequate physical exam.

A critical appraisal of AHRQ's "Diagnostic Errors" report.

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Carpenter C, Jotte R, Griffey RT, et al. Mo Med. 2023;120:114-120.

AHRQ's 2022 report Diagnostic Errors in the Emergency Department: A Systematic Review, which reported an estimated 7.4 million patients receive a misdiagnosis in the emergency department every year, garnered public, practitioner, and researcher attention. In this peer-reviewed commentary, the authors critique several components of the report. They also support AHRQ's recommended next steps, and further call for additional public and private funding opportunities to continue improving diagnostic accuracy in the emergency department.

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