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.
Hailu EM, Maddali SR, Snowden JM, et al. Health Place. 2022;78:102923.
Racial and ethnic health disparities are receiving increased attention, and yet structural racism continues to negatively impact communities of color. This review identified only six papers studying the impact of structural racism on severe maternal morbidity (SMM). Despite heterogeneity in measures and outcomes, the studies all demonstrated a link between structural racism and SMM; additional research is required.
Henry Basil J, Premakumar CM, Mhd Ali A, et al. Drug Saf. 2022;45:1457-1476.
Medication administration errors (MAEs) are thought to be common in neonatal intensive care units (NICUs). This systematic review estimated that the pooled prevalence of MAEs among patients in NICU settings ranged from 59% to 65%. The review highlights both active failures (e.g., similar drug packaging or names) and latent failures (e.g., noisy environments, inaccurate verbal or written orders) contributing to MAEs.
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.
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.
Bernstein SL, Kelechi TJ, Catchpole K, et al. Worldviews Evid Based Nurs. 2021;18:352-360.
Failure to rescue, the delayed or missed recognition of a potentially fatal complication that results in the patient’s death, is particularly tragic in obstetric care. Using the Systems Engineering Initiative for Patient Safety (SEIPS) framework, the authors describe the work system, process, and outcomes related to failure to rescue, and develop intervention theories.
Keister LA, Stecher C, Aronson B, et al. BMC Public Health. 2021;21:1518.
Constrained diagnostic situations in the emergency department (ED), such as crowding, can impact safe care. Based on multiple years of electronic health record data from one ED at a large U.S. hospital, researchers found that providers were significantly less likely to prescribe opioids during constrained diagnostic situations and less likely to prescribe opioids to high-risk patients or racial/ethnic minorities.
Petrosoniak A, Fan M, Hicks CM, et al. BMJ Qual Saf. 2021;30:739-746.
Trauma resuscitation is a complex, specialized process with a high risk for errors. Researchers analyzed videotapes of in situ simulations to evaluate latent safety events occurring during trauma resuscitation. Themes influencing latent safety events related to physical workspace, mental model formation, equipment, unclear accountability, demands exceeding individuals’ capacity, and task-specific issues.
Avesar M, Erez A, Essakow J, et al. Diagnosis (Berl). 2021;8:358-367.
Disruptive and rude behavior can hinder teamwork and diminish patient safety. This randomized, simulation-based study including attendings, fellows, and residents explored whether rudeness during handoff affects the likelihood for challenging a diagnostic error. The authors found that rudeness may disproportionally hinder diagnostic performance among less experienced physicians.
Donovan AL, Aaronson EL, Black L, et al. Jt Comm J Qual Patient Saf. 2021;47:23-30.
Patient suicide, attempted suicide, or self-harm are considered ‘never events.’ This article describes the development and implementation of a safety protocol for emergency department (ED) patients at risk for self-harm, including the creation of safe bathrooms and increasing the number of trained observers in the ED. Implementation of the protocol was correlated with lower rates of self-harm.
Pelaccia T, Messman AM, Kline JA. Patient Edu Couns. 2020;103:1650-1656.
The hectic and complex environment of emergency care can reduce diagnostic safety. This article discusses clinical reasoning and decision-making strategies used by emergency medicine physicians, contributing factors to diagnostic errors occurring in emergency medicine (e.g., overconfidence, cognitive stress, anchoring bias), and strategies to reduce the risk of error. A previous WebM&M commentary discussed an incident involving diagnostic delay in the emergency department.
Pulia M, Wolf I, Schulz L, et al. West J Emerg Med. 2020;21:1283-1286.
Antimicrobial stewardship is one strategy to improve antibiotic use to reduce hospital-acquired infections. In this editorial, the authors discuss negative effects of COVID-19 on antimicrobial resistance and antibiotic stewardship in the emergency department (ED) and approaches for optimizing ED stewardship during the pandemic.
Lau VI, Priestap FA, Lam JNH, et al. J Intensive Care Med. 2020;35:1067-1073.
Many factors can contribute to early, unplanned readmissions among critical care patients. In this prospective cohort study, adult patients who were discharged directly home after an ICU admission were followed for 8 weeks post-discharge to explore the predictors of adverse events and unplanned return visits to a health care facility. Among 129 patients, there were 39 unplanned return visits. Researchers identified eight predictors of unplanned return visits including prior substance abuse, hepatitis, discharge diagnosis of sepsis, ICU length of stay exceeding 2 days, nursing workload, and leaving against medical advice.
Vanneman MW, Balakrishna A, Lang AL, et al. Anesth Analg. 2020;131:1217-1227.
Transfusion errors due to patient misidentification can have serious consequences. This article describes the implementation of an automated, electronic barcode scanner system to improve pretransfusion verification and documentation. Over two years, the system improved documentation compliance and averted transfusion of mismatched blood products in 20 patients.
Fortman E, Hettinger AZ, Howe JL, et al. J Am Med Info Assoc. 2020;27:924-928.
Physicians from different health systems using two computerized provider order entry (CPOE) systems participated in simulated patient scenarios using eye movement recordings to determine whether the physician looked at patient-identifying information when placing orders. The rate of patient identification overall was 62%, but the rate varied by CPOE system. An expert panel identified three potential reasons for this variation – visual clutter and information density, the number of charts open at any given time, and the importance placed on patient identification verification by institutions.
Plint AC, Stang A, Newton AS, et al. BMJ Qual Saf. 2021;30:216-227.
This article describes emergency department (ED)-related adverse events in pediatric patients presenting to the ED at a pediatric hospital in Canada over a one-year period. Among 1,319 patients at 3-months follow-up, 33 patients (2.5%) reported an adverse event related to their ED care. The majority of these events (88%) were preventable. Most of the events involved diagnostic (45.5%) or management issues (51.5%) and resulted in symptoms lasting more than one day (72.7%).
Sanson G, Marino C, Valenti A, et al. Heart & Lung. 2020;49:407-414.
Prospective observational study examined whether nursing complexity level predicts adverse event risk among patients transferred from the ICU to the discharge ward. In this 13-bed ICU, researchers found that various factors including level of acuity and nursing complexity predated risk of adverse events (AEs); patients who exceeded a predetermined complexity threshold were at 3-times greater risk of AEs.
Isbell LM, Boudreaux ED, Chimowitz H, et al. BMJ Qual Saf. 2020;29:815–825.
Research has suggested that health care providers’ emotions may impact patient safety. These authors conducted 86 semi-structured interviews with emergency department (ED) nurses and physicians to better understand their emotional triggers, beliefs about emotional influences on patient safety, and emotional management strategies. Patients often triggered both positive and negative emotions; hospital- or systems-level factors primarily triggered negative emotions. Providers were aware that negative emotions can adversely impact clinical decision-making and place patients at risk; future research should explore whether emotional regulation strategies can mitigate these safety risks.
Soffin EM, Lee BH, Kumar KK, et al. Br J Anaesth. 2019;122:e198-e208.
Reducing opioid prescribing in pain management is a key strategy to address the opioid crisis. This review highlights the unique role of the anesthesiologist in this approach. The authors emphasize preoperative identification of patients at risk for long-term opioid use and suggest organizational, clinical, and research strategies that can be led by anesthesiologists to reduce opioid use.
The FDA recently raised awareness of the potential risks associated with the use of robotic-assisted surgical devices in mastectomies or cancer-related care. This commentary spotlights how payers, hospitals, and clinicians can prevent harm related to robotic surgical device use. Strategies to improve safety include enhanced credentialing, device-specific training, and informed consent. A WebM&M commentary discussed an incident of harm associated with robotic-assisted surgery.
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