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 62 Results

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.

Improving Diagnostic Safety and Quality

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Perspective on Safety April 26, 2023

Throughout 2022, AHRQ PSNet has shared research that elucidates the complex nature of misdiagnosis and diagnostic safety. This Year in Review explores recent work in diagnostic safety and ways that greater safety may be promoted using tools developed to improve diagnostic practices.

Crisis scenarios for simulation-based nontechnical skills training for cardiac surgery teams: a national survey among cardiac anesthesiologists, cardiac surgeons, clinical perfusionists, and cardiac operating room nurses.

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Kemper T, van Haperen M, Eberl S, et al. Simul Healthc. 2023;Epub Mar 6.

Simulation-based training provides a safe environment to learn technical and nontechnical skills (NTS) such as communication and teamwork. This article describes the development of nontechnical, simulation-based crisis scenarios in cardiothoracic surgery. Cardiac surgeons, cardiac anesthesiologists, cardiac perfusionists, and cardiac operating room nurses from all surgical cardiac centers in the Netherlands participated in the development of 13 crisis scenarios. The list of selected and non-selected scenarios and an example scenario design template are provided.

Distractions in the operating room: a survey of the healthcare team.

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Nasri B-N, Mitchell JD, Jackson C, et al. Surg Endosc. 2023;37:2316-2325.

Distractions in the operating room can contribute to errors. Based on survey responses from 160 healthcare workers, this study examined perceived distractions in the operating room. All participants ranked auditory distractions as the most distracting and visual distractions as the least distracting, but the top five distractors fell into the equipment and environmental categories – (excessive heat/cold, team member unavailability, poor ergonomics, equipment unavailability, and competitive demand for equipment). Phone calls/pagers/beepers were also cited as a common distractor.

Surgeons and systems working together to drive safety and quality.

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Hawkins RB, Nallamothu BK. BMJ Qual Saf. 2023;32:181-184.

A 2022 study found that non-first off-pump coronary artery bypass graft (CABG) had a higher risk of complications than first cases, proposing prior workload as a contributing cause. This commentary responds to that study, proposing system and organizational factors, not just the individual surgeon, be taken into consideration as contributing causes.

Crowding in the Emergency Department: Challenges for the Care of Children.

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Gross TK, Lane NE, Timm NL, et al. Pediatrics. 2023;151:e2022060971-e2022060972.

Emergency room crowding is a persistent factor that degrades safety for patients of all ages. This collection provides background, best practices, and recommendations to reduce emergency department crowding and its negative impact on pediatric care. The publications examine factors that influence crowding and improvement at the input, departmental, and hospital/outpatient stages of emergency care.

Examination of impact of after-hours admissions on hospital resource use, patient outcomes, and costs.

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Skead C, Thompson LH, Kuk H, et al. Crit Care Res Pract. 2022;2022:4815734.

After-hours and weekend admissions to the hospital and intensive care units (ICU) have been linked to poor outcomes. This retrospective analysis compared outcomes among adult patients with daytime versus nighttime ICU admissions at one large Canadian medical center in between 2011 and 2015. Researchers found that overall mortality, but not ICU mortality, was higher among daytime admissions.

Diagnostic Errors in the Emergency Department: A Systematic Review.

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Newman-Toker DE, Peterson SM, Badihian S, et al. Rockville, MD: Agency for Healthcare Research and Quality; December 2022. AHRQ Publication No. 22(23)-EHC043.

Although diagnostic accuracy in the emergency department (ED) is high, diagnostic errors still occur. This evidence review estimated that 1 in 18 ED patients receive an incorrect diagnosis, which translates to 7.4 million patients misdiagnosed every year (or 5.7% of all ED visits annually). Five conditions were found to be most vulnerable to misdiagnosis: stroke, heart attack, aortic aneurysm/ dissection, spinal cord injury and blood clots. The evidence review identified variation in diagnostic error rates across demographic groups; female sex and non-White race were often associated with increased risk for diagnostic errors. Serious misdiagnosis-related harms were often associated with clinician bedside judgement and other cognitive failures. The report was updated August 14, 2023, and now includes addendum, errata, and updated author conflict of interest disclosures with corresponding mitigation plan. The webpage also has a listing of comments received during the public comment period and responses from the authors.

Structural racism and adverse maternal health outcomes: a systematic review.

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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.

Curated Libraries

Diagnostic Safety

October 10, 2022

Selected PSNet materials for a general safety audience focusing on improvements in the diagnostic process and the strategies that support them to prevent diagnostic errors from harming patients.

Emergency department adverse events detected using the emergency department trigger tool.

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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.

Society for Maternal-Fetal Medicine Special Statement: cognitive bias and medical error in obstetrics-challenges and opportunities.

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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.

A new index for obstetrics safety and quality of care: integrating cesarean delivery rates with maternal and neonatal outcomes.

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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.

Does standardisation improve post-operative anaesthesia handoffs? Meta-analyses on provider, patient, organisational, and handoff outcomes.

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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.

Assessing quality of older persons' emergency transitions between long-term and acute care settings: a proof-of-concept study.

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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.

The effect of clinician feedback interventions on opioid prescribing.

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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.

Surgeon burnout, impact on patient safety and professionalism: a systematic review and meta-analysis.

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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.

Intraoperative deaths: who, why, and can we prevent them?

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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.

Association between handover of anesthesiology care and 1-year mortality among adults undergoing cardiac surgery.

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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.

Psychometric properties of the perinatal missed care survey and missed care during labor and birth.

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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.

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