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.
Dillner P, Eggenschwiler LC, Rutjes AWS, et al. BMJ Qual Saf. 2022;Epub Dec 26.
Retrospective error detection methods, such as trigger tools, are widely used to uncover the incidence and characteristics of adverse events (AE) in hospitalized children. This review sought AEs identified by three trigger tools: Global Trigger Tool (GTT), the Trigger Tool (TT) or the Harvard Medical Practice Study (HMPS) method. Results from the trigger tools were widely variable, similar to an earlier review in adult acute care, and suggest the need for strengthening reporting standards.
Oura P, Sajantila A. J Public Health Res. 2022;11:227990362211399.
Although patient safety is a national priority, preventable harm among patients remains high. After analyzing national death certificate data from 1999 through 2019, researchers in this study found that medical adverse events were listed as the underlying cause of death in 0.24% of deaths. From 2014 to 2019, researchers identified a nearly 16% annual increase in deaths attributed to adverse events, primarily driven by procedure-related adverse events and possibly related to the implementation of ICD-10 in 2015.
Trigger tools alert patient safety personnel to potential adverse events (AE) which can then be followed up with retrospective chart review. This review sought to understand the variability in adverse event detection in acute care and study characteristics that may explain the variation. Fifty-four studies were included with a wide range of AEs detected per 100 admissions. The authors suggest developing guidelines for studies reporting on AEs identified using trigger tools to decrease study heterogeneity.
Ahsani-Estahbanati E, Sergeevich Gordeev V, Doshmangir L. Front Med (Lausanne). 2022;9:875426.
Hospital-acquired conditions impact not only patient morbidity and mortality, but are also a significant financial burden. This review identified eight categories of hospital-acquired conditions (i.e., overall medical error, medication error, diagnostic error, patient falls, healthcare-associated infections, transfusion and testing errors, surgical error, and patient suicide) and more than 100 proposed interventions addressing those conditions.
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.
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.
Eldridge N, Wang Y, Metersky M, et al. JAMA. 2022;328:173-183.
Improving patient safety in hospitals is a longstanding national priority. Using longitudinal Medicare data from 2010 to 2019, this study identified a significant decrease in the rates of adverse events (e.g., adverse drug events, hospital-acquired infections, postoperative adverse events, hospital-acquired pressure ulcers, falls) over time among patients hospitalized for four common conditions – acute myocardial infarction, heart failure, pneumonia, and surgical procedures.
Nowak B, Schwendimann R, Lyrer P, et al. Int J Environ Res Public Health. 2022;19:2796.
Diagnostic error and misdiagnosis of stroke patients can lead to preventable adverse events, such as treatment delays and adverse outcomes. Researchers at a Swiss hospital retrospective reviewed patients admitted for transient ischemic attack (TIA) or ischemic stroke and found that a trigger tool could accurately identify preventable events among patients with adverse events and no-harm incidents. The most common preventable events were medication events, pressure injuries, and healthcare-associated infections.
Damoiseaux-Volman BA, Raven K, Sent D, et al. Age Ageing. 2022;51:afab205.
According to an Agency for Healthcare Research and Quality study, an estimated 700,000 to 1 million hospitalized patients fall each year. This study assessed the impact of potentially inappropriate medications (PIM) on falls in older adults and compared the impact of three deprescribing tools on inpatient falls. PIMs identified by section K of the Screening Tool of Older Persons' Prescriptions (STOPP) had the strongest association with inpatient falls.
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.
Patient isolation for infection prevention and control may result in unintended consequences. This systematic review examined adverse physical and psychosocial events associated with patient isolation. A meta-analysis of seven observational studies showed no adverse events related to clinical care or patient experience with isolation.
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).
Kuznetsova M, Frits ML, Dulgarian S, et al. JAMIA Open. 2021;4:ooab096.
Dashboards can be used to synthesize data and visualize patient safety indicators and metrics to facilitate decision-making. The authors reviewed design features of patient safety dashboards from 10 hospitals and discuss the variation in the use of performance indicators, style, and timeframe for displayed metrics. The authors suggest that future research explore how specific design elements contribute to usability, and which approaches are associated with improved outcomes.
Patient boarding in the emergency department (ED) can result in patient harm. This review explored the association between boarding in the ED and quality of care, outcomes, and adverse events. Increased boarding time was associated with poorer quality of care and outcomes.
van der Kooi T, Lepape A, Astagneau P, et al. Euro Surveill. 2021;26.
Healthcare-associated infections (HAIs) contribute to patient morbidity and mortality every year. Three mortality review measures were developed to measure the potential contribution of HAIs to patient death. All three measures showed acceptable feasibility, validity, and reproducibility in HAI surveillance.
Mangal S, Pho A, Arcia A, et al. Jt Comm J Qual Patient Saf. 2021;47:591-603.
Interventions to prevent catheter-associated urinary tract infections (CAUTI) can include multiple components such as checklists and provider communication. This systematic review focused on CAUTI prevention interventions that included patient and family engagement. All included studies showed some improvement in CAUTI rates and/or patient- and family-related outcomes. Future research is needed to develop more generalizable interventions.
Marang-van de Mheen PJ, Vincent CA. BMJ Qual Saf. 2021;30:525-528.
Research has shown that patients admitted to the hospital on the weekend may experience worse outcomes compared to those admitted on weekdays (the ‘weekend effect’). This editorial highlights the challenges to empirically evaluate the underlying mechanisms contributing to the weekend effect. The authors propose viewing the weekend effect as a proxy for staffing levels and the influence of other factors influencing outcomes for patients admitted on weekends, such as patient acuity, clinician skill-mix and access to diagnostic tests or other ancillary services.
Pati D, Valipoor S, Lorusso L, et al. J Patient Saf. 2021;17:273-281.
Decreasing inpatient falls requires improvements in both processes of care and the care environment. This integrative review found that some elements of the built environments have not been rigorously examined and concluded that objective and actionable knowledge on physical design solutions to reduce falls is limited.
Farhat A, Al‐Hajje A, Csajka C, et al. J Clin Pharm Ther. 2021;46:877-886.
Several tools have been developed to reduce potentially inappropriate prescribing. This study explored the economic and clinical impacts of two tools, STOPP/START and FORTA (Fit fOR The Aged list). Randomized controlled trials (RCTs) using those tools demonstrated significant clinical and economic impact in geriatric and internal medicine. Due to the low number of RCT studies evaluating these tools, additional studies are warranted.
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