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.
Carmack A, Valleru J, Randall KH, et al. Jt Comm J Qual Patient Saf. 2022;Epub Sep 30.
Retained surgical items (RSI) are a never event, a serious and preventable event. After experiencing a high rate of RSIs, this United States health system implemented a bundle to reduce RSI, improve near-miss reporting, and increase process reliability in operating rooms. The bundle consisted of five elements: surgical stop, surgical debrief, visual counters, imaging, and reporting.
Healthcare professionals involved in a medical error often experience psychological distress. This article describes the validation of a revised version of the Second Victim Experience and Support Tool (SVEST-R), which was expanded to include measures of resilience and desired forms of support.
Infant misidentification or abduction are considered never events. This article discusses the results of a failure mode and effects analysis to identify and eliminate or reduce the risk of infant misidentification or abduction. Twenty-eight failure modes were identified; the highest-ranked items involved concerns for uninvited individuals on the unit, interactions with child-protective services, alarm fatigue, and inadequate identification checks of the infants with mothers.
Weprin SA, Meyer D, Li R, et al. Patient Saf Surg. 2021;15:14.
A retained surgical sharp (RSS) is a never event. Operating room (OR) team members, including surgeons, anesthesiologists, and nurses, were surveyed regarding their experiences with actual and near-miss sharps (NMS). While nearly all team members reported experiencing at least one RSS or NMS in the past year, responses to other survey items varied by professional group. Surgeons were less likely to perceive that a sharp had been lost as compared to other OR team members, indicating a potential under-report bias. Improved communication between team members may increase identification, and therefore reporting, of RSS and NMS, to prevent similar incidents in the future.
Shaikh U, Natale JAE, Till DA, et al. Pediatr Emerg Care. 2022;38:e283-e286.
Incident reporting systems may be underutilized by medical trainees. This article describes a brief, interactive simulation activity to improve identification and reporting of patient safety hazards among medical students and interns.
This commentary presents two cases of near-miss wrong-patient order errors between mother-newborn pairs and discusses the unique threat the postpartum setting presents to electronic order safety. The article highlights opportunities for systems improvement.
Landrigan CP, Rahman SA, Sullivan JP, et al. N Engl J Med. 2020;382:2514-2523.
This multicenter cluster randomized trial explored the impact of eliminating extended-duration work schedules (shifts in excess of 24 hours) on serious medical errors made by residents in the pediatric intensive care unit (ICU). The authors found that residents in ICUs which eliminated extended shifts in favor of day and night shifts of 16 hours or less made significantly more serious errors than residents assigned to extended-duration work schedules. The authors observed that the resident-to-patient ratio was higher during schedules which eliminated extended shifts, but also that these results might have been confounded by concurrent increases in workload in ICUs eliminating extended shifts.
The good catch, or near miss, can provide a key learning experience in health care practice. This article discusses the importance of organizational culture in utilizing these experiences as improvement opportunities. The author reviews strategies for nurses to engage in skill development through case review of good catches.
The Joint Commission and National Quality Forum both consider wrong-site, wrong-procedure, and wrong-patient surgeries to be never events. Despite improvement approaches ranging from the Universal Protocol to nonpayment for the procedures themselves and any consequent care, these serious surgical errors continue to occur. This study measured the incidence of incorrect surgeries in Veterans Health Administration medical centers from 2010 to 2017. Surgical patient safety events resulting in harm were rare and declined by more than two-thirds from 2000 to 2017. Dentistry, ophthalmology, and neurosurgery had the highest incidence of in–operating room adverse events. Root cause analysis revealed that 29% of events could have been prevented with a correctly performed time-out. A WebM&M commentary examined an incident involving a wrong-side surgery.
Shah D, Manzi S. Pediatr Emerg Care. 2018;34:497-500.
Clinical pharmacist supervision improves medication safety in many health care settings. In this study, pharmacists in a pediatric emergency department (ED) reviewed all discharge prescriptions the day after patients left the ED and contacted prescribers to address safety hazards. Over a 1-year period, pharmacists intervened rarely (0.25% of prescriptions), averted 10 incidents of moderate or major harm, and worked 45 additional minutes per day.
Lozito M, Whiteman K, Swanson-Biearman B, et al. AORN J. 2018;107:705-714.
This quality improvement initiative developed and promoted reporting of good catches—recognition of incipient patient safety problems—in the perioperative setting. The authors reported improvement in safety culture scores, as measured by the AHRQ Hospital Survey on Patient Safety Culture, after implementation of the program compared to prior scores.
Hamilton EC, Pham DH, Minzenmayer AN, et al. J Surg Res. 2018;221:336-342.
This study compared direct observation to voluntary reporting for identification of errors and near misses in pediatric surgery. As with prior studies, the team observed underreporting of adverse events and near misses. The authors advocate for systems approaches to enhance reporting.
Case studies of adverse events and near misses provide context to inform improvements. This commentary offers insights from four examples of near misses and highlights strategies such as the use of the 10 rights of drug administration, near-miss reporting, shared accountability for safety, and dedication to learning as drivers for medication safety efforts.
O'Mahoney PRA, Yeo HL, Lange MM, et al. Surg Innov. 2016;23:337-40.
Although using video documentation while providing care is controversial, it has been shown to contribute to error and near miss analysis. This commentary describes how utilizing videos in operating rooms can enhance patient safety and clinician accountability.
Despite efforts to prevent wrong-site surgeries, they continue to occur. This commentary discusses a near miss resulting from human factors and inadequate team communication to underscore the importance of reporting and analyzing incidents to enhance individual practice and teamwork.
White WA, Kennedy K, Belgum HS, et al. Jt Comm J Qual Patient Saf. 2015;41:550-560.
Serious reportable events in hospitals are usually captured, but less serious events and near misses often go undocumented. Such close calls can reveal important safety hazards. This study describes the development and early experience of an active surveillance program in a pediatric intensive care unit (PICU). Under the supervision of an assigned intensive care physician, premedical college graduates served as quality/safety analysts. Two analysts canvassed the PICU each morning, interviewing night nurses, physicians, respiratory therapists, and pharmacists about potential adverse events. Over a 15-month period, 2465 events were recorded, representing 5.4 events per day. Approximately 158 quality and safety improvement projects were initiated during this period. The authors describe the infrastructure, reporting, and unique web application that were developed as a part of this process. These quality/safety analyst interviews essentially created a facilitated, robust voluntary incident reporting system.
This study of incident reports from pediatric emergency departments found that a small proportion reported near misses or unsafe conditions. Common issues included medication safety, handoffs, human factors, and systems vulnerabilities, all of which are known to lead to patient harm. Prior studies have found that incident reporting is often underused. This study highlights its importance as a lens into safety problems.
Lipshutz AKM, Caldwell JE, Robinowitz DL, et al. BMC Anesthesiol. 2015;15:93.
This analysis of near misses in intensive care unit patients that were voluntarily reported by anesthesiologists found that the majority could be ascribed to one of five contributing factors, including a poor culture of safety and insufficient communication between teams.
Bonrath EM, Gordon LE, Grantcharov TP. BMJ Qual Saf. 2015;24:516-21.
This series of blinded video reviews of laparoscopic surgeries identified the technical surgical errors that led to complications. This study adds to the emerging evidence supporting peer review of operating room videos. A recent AHRQ WebM&M interview with John Birkmeyer discussed his video study that found a link between practicing surgeons' directly observed technical skills and surgical safety outcomes.
By tracking improper surgical bookings and observing time-out procedures, this study measured near misses for wrong-site surgery and provided education about correct procedures when they encountered errors. After this education, surgical booking and time-out procedures improved.
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