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.
Previous research has found that fear of malpractice can influence medical decision-making. This survey of emergency department attending physicians and advanced practice clinicians in Massachusetts found that fear of harming patients played a larger role in medical decision-making than fear of legal action.
Griffey RT, Schneider RM, Todorov AA. Ann Emerg Med. 2022;80:528-538.
Trigger tools are a novel method of detecting adverse events. This article describes the location, severity, omission/commission, and type of adverse events retrospectively detected using the computerized Emergency Department Trigger Tool (EDTT). Understanding the characteristics of prior adverse events can guide future quality and safety improvement efforts.
Parker H, Frost J, Day J, et al. PLoS ONE. 2022;17:e0271454.
Prophylactic antimicrobials are frequently prescribed for surgical patients despite the risks of antimicrobial overuse (e.g., resistance). This review summarizes how and why antimicrobials continue to be prescribed in surgical settings despite evidence of overuse. Eight overarching concepts were identified: hierarchy; fear drives action; deprioritized; convention trumps evidence; complex judgments; discontinuity of care; team dynamics; and practice environment.
Atallah F, Hamm RF, Davidson CM, et al. Am J Obstet Gynecol. 2022;227:b2-b10.
The reduction of cognitive bias is generating increased interest as a diagnostic error reduction strategy. This statement introduces the concept of cognitive bias and discusses methods to manage the presence of bias in obstetrics such as debiasing training and teamwork.
Marsh KM, Fleming MA, Turrentine FE, et al. J Pediatr Surg. 2022;57:616-621.
Patient safety improvement can be hindered by lack of effective measurement tools. This scoping review explored how medical errors are defined and measured in studies of pediatric surgery patients. The authors identified several evidence gaps, including absence of standardized error definitions.
Krenzischek DA, Card E, Mamaril M, et al. J Perianesth Nurs. 2022;37:827-833.
Patients and caregivers are important partners in promoting safe care. Findings from this cross-sectional study reinforce the importance of patients’ perceived roles in ensuring safe surgery and highlight the importance of patient engagement in mitigating surgical site errors.
Ramani S, Halpern TA, Akerman M, et al. Am J Obstet Gynecol. 2022;226:556.e1-556.e9.
Cesarean delivery can lead to adverse outcomes and is commonly used as a measure of obstetrical quality; however, these measures do not account for preexisting maternal and neonatal morbidities, which may increase risk for cesarean delivery. This article describes the development and testing of a new obstetrical quality measure that integrates cesarean delivery rates adjusted for preexisting high-risk maternal factors as well as maternal and neonatal morbidities. Among obstetricians in one large hospital, researchers found that this metric led to significantly different clinician rankings in terms of obstetrical quality (compared to rankings based on crude or adjusted cesarean delivery rates alone.) The authors suggest that this new metric can help identify opportunities for practice improvement among individual clinicians and institutions.
Lazzara EH, Simonson RJ, Gisick LM, et al. Ergonomics. 2022;65:1138-1153.
Structured handoffs support appropriate communication between teams or departments when transferring responsibility for care. This meta-analysis aimed to determine if structured, standardized post-operative anesthesia handoffs improved provider, patient, organizational and handoff outcomes. Postoperative outcomes moved in a generally positive direction when compared with non-standardized handoffs. The authors suggest additional research into pre- and intra-operative handoffs is needed.
Understanding human causes of diagnostic errors can lead to more specific targeted, specific recommendations and interventions. Using three classification instruments, researchers examined a series of serious adverse events related to diagnostic errors in the emergency department. Most of the human errors were based on intended actions and could be classified as mistakes or violations. Errors were more frequently made during the assessment and testing phases of the diagnostic process.
Tate K, McLane P, Reid C, et al. BMJ Open Qual. 2022;11:e001639.
Older adults are vulnerable to patient safety events during care transitions. The Older Persons’ Transitions in Care (OPTIC) study prospectively tracked long-term care residents’ transitions and applied the IOM’s quality of care domains to develop 49 measures for quality of care for the transition process (e.g., safety, timeliness, efficiency, effectiveness, and patient-centered care) between long-term care and emergency department settings.
Navathe AS, Liao JM, Yan XS, et al. Health Aff (Millwood). 2022;41:424-433.
Opioid overdose and misuse continues to be a major public health concern with numerous policy- and organization-level approaches to encourage appropriate clinician prescribing. A northern California health system studied the effects of three interventions (individual audit feedback, peer comparison, both combined) as compared to usual care at several emergency department and urgent care sites. Peer comparison and the combined interventions resulted in a significant decrease in pills per prescription.
Al-Ghunaim TA, Johnson J, Biyani CS, et al. Am J Surg. 2022;224:228-238.
Burnout in healthcare providers has been linked to lower patient safety and increased adverse events. This systematic review examined studies focusing on the relationship between burnout and patient safety and professionalism in surgeons. Results indicate higher rates of burnout and emotional exhaustion were associated with an increased risk of involvement in medical error. Interventions to reduce burnout and improve surgeon well-being may result in improved patient safety.
Dorken Gallastegi A, Mikdad S, Kapoen C, et al. J Surg Res. 2022;274:185-195.
While interoperative deaths (IODs) are rare, they are catastrophic events. This study analyzed five years of data on IODs from a large academic medical center. The authors describe three phenotypes: patients with traumatic injury, those undergoing non-trauma-related emergency surgery, and patients who die during an elective procedure from medical cardiac arrests or vascular injuries. This classification framework can serve as a foundation for future research or quality improvement processes.
Sun LY, Jones PM, Wijeysundera DN, et al. JAMA Netw Open. 2022;5:e2148161.
Previous research identified a relationship between anesthesia handoffs and rates of major complications and mortality compared to patients who had the same anesthesiologist throughout their procedure. This retrospective cohort study including over 102,000 patients in Ontario, Canada, explored this relationship among patients undergoing cardiac surgery. Analyses revealed that anesthesia handovers were associated with poorer outcomes (i.e., higher 30-day and one-year mortality rates, longer hospitalizations and intensive care unit stays) compared with patients who had the same anesthesiologist throughout their procedure.
Bastakoti M, Muhailan M, Nassar A, et al. Diagnosis. 2022;9:107-114.
Misdiagnosis in the emergency department (ED) can result in increased morbidity and mortality. This retrospective chart review of patients admitted from the ED to hospital explored the concordance of ED admission and hospital discharge diagnoses. Results show 21.77% of patients had discordant diagnoses; discordant diagnosis was associated with increased length of stay, mortality, and up-triage to ICU.
Rivera-Chiauzzi EY, Smith HA, Moore-Murray T, et al. J Patient Saf. 2022;18:e308-e314.
Peer support programs are increasingly used to support clinicians involved in adverse events. This evaluation found that a structured peer support program for providers involved in obstetric adverse events can effectively support providers in short periods of time (for example, 92% of participants did not need follow-up after second peer support contact) and can be initiated with limited resources.
Lyndon A, Simpson KR, Spetz J, et al. Appl Nurs Res. 2022;63:151516.
Missed nursing care appears to be associated with higher rates of adverse events. More than 3,600 registered nurses (RNs) were surveyed about missed care during labor and birth in the United States. Three aspects of nursing care were reported missing by respondents: thorough review of prenatal records, missed timely documentation of maternal-fetal assessments, and failure to monitor input and output.
Okpalauwaekwe U, Tzeng H-M. Patient Relat Outcome Meas. 2021;12:323-337.
Patients transferred from hospitals to skilled nursing facilities (SNFs) are vulnerable to adverse events. This scoping review identified common extrinsic factors contributing to adverse events among older adults during rehabilitation stays at skilled nursing facilities, including inappropriate medication usage, polypharmacy, environmental hazards, poor communication between staff, lack of resident safety plans, and poor quality of care due to racial bias, organizational issues, and administrative issues.
Gillespie BM, Harbeck EL, Rattray M, et al. Int J Surg. 2021;95:106136.
Surgical site infections (SSI) are a common, yet largely preventable, complication of surgery which can result in increased length of stay and hospital readmission. In this review of 57 studies, the cumulative incidence of SSI was 11% in adult general surgical patients and was associated with increased length of stay (with variation by types of surgery).
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