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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 30 Results
Boquet A, Cohen T, Diljohn F, et al. J Patient Saf. 2021;17:e534-e539.
This study classified flow disruptions affecting the anesthesia team during cardiothoracic surgeries. Disruptions were classified into one of six human factors categories: communication, coordination, equipment issues, interruptions, layout, and usability. Interruptions accounted for nearly 40% of disruptions (e.g., events related to alerts, distractions, searching activity, spilling/dropping, teaching moment).
Bubric KA, Biesbroek SL, Laberge JC, et al. Jt Comm J Qual Patient Saf. 2021;47:556-562.
Unintentionally retained foreign objects (RFO) following surgery is a never event. In this study, researchers observed 36 surgical procedures to quantify and describe interruptions and distractions present during surgical counting. Interruptions (e.g., the surgeon or another nurse talking to the scrub nurse) and distractions (e.g., music, background noise) were common. Several suggestions to minimize interruptions and distractions during surgical counts are made.
Bonafide CP, Miller JM, Localio AR, et al. JAMA Pediatr. 2019;174:162-169.
Interruptions are common in busy clinical settings but carry patient safety concerns, particularly if they occur during medication administration. This retrospective cohort study examined one hospital’s timestamped telecommunications data to determine the effect of incoming mobile calls or texts on subsequent medication errors (based on barcode alerts) in a pediatric ICU. Medication administration errors were more common when nurses were interrupted by incoming telephone calls (3.7%) compared to when they were uninterrupted (3.1%), and error risk varied by shift, level of experience, nurse to patient ratio, and level of patient care required. Incoming text messages were not associated with medication administration errors; the authors speculate that this may be attributable to the fact that text message alerts do not require immediate response or that nurses have become accustomed to their frequent occurrence.
Khairat S, Whitt S, Craven CK, et al. J Patient Saf. 2021;17:e321-e326.
Despite many technological innovations, safety events occur frequently in critical care settings. This observational study of critical care rounds found that more safety events occurred when technology such as computer alerts, phones, and pagers interrupted physicians. A previous WebM&M commentary discussed an incident involving a technology interruption that led to serious patient harm.
Olmstead J. Nurs Manage. 2019;50:8-10.
Mistakes during handoffs from the emergency department (ED) to inpatient units can diminish patient safety. This commentary summarizes how one hospital sought to to avoid miscommunications and disruptions by blocking admission of ED transfers during shift report. However, researchers found that blocking patient transfers did not result in improvements. The project did devise a standardized handoff process that was ultimately employed across the organization as a patient safety strategy.
Joseph A, Khoshkenar A, Taaffe KM, et al. BMJ Qual Saf. 2019;28:276-283.
This direct observation study found that minor disruptions in usual workflow can combine to lead to an adverse event. More than half of the observed disruptions were related to the physical layout of the operating room, suggesting that physical design of operating rooms may affect surgical safety.
Craker NC, Myers RA, Eid J, et al. J Nurs Adm. 2017;47:205-211.
Interruptions are a known patient safety hazard. This direct observation study demonstrated that intensive care unit nurses were interrupted about every 20 minutes. Interruptions by physicians were of longer duration and were more likely to result in the nurse moving to another activity. The authors conclude that further study is needed to determine the clinical significance of interruptions in the intensive care unit setting.
Allan SH, Doyle PA, Sapirstein A, et al. Jt Comm J Qual Patient Saf. 2017;43:62-70.
Reducing the number of alarms can help alleviate alarm fatigue and the associated patient safety hazards. In this study, researchers successfully implemented a number of interventions which led to a 61% decrease in average alarms per monitored bed in a cardiovascular surgical intensive care unit and a reduction in cardiorespiratory events.
Snoots LR, Wands BA. AANA J. 2016;84:114-119.
Personal electronic devices such as smartphones are now ubiquitous, and many clinicians use them for both work and personal purposes. Although considered a necessity, these devices can serve as a distraction, which could compromise patient safety. This review found that many certified registered nurse anesthetists and anesthesiologists acknowledge using personal electronic devices in the operating room despite knowledge of the potential risks. Currently, no formal guidelines exist regarding what constitutes inappropriate use of such devices in the operating room. The authors call for further research in order to develop policies to balance the risks and benefits of personal electronic devices. A WebM&M commentary discusses a case where an interruption due to receiving a text message on a smartphone led to a serious medication error.
Werner NE, Holden RJ. Appl Ergon. 2015;51:244-54.
Interruptions are a known safety hazard that occur frequently. This systematic review proposes that interruptions be considered a process with various potential consequences for multiple actors rather than single events and suggests a human factors approach to addressing interruptions.
Cole G, Stefanus D, Gardner H, et al. BMJ Qual Saf. 2016;25:457-65.
Interruptions are inevitable in the clinical environment, and they have been linked to an increased risk of diagnostic errors by radiologists and medication administration errors by nurses. However, the effects of interruptions are not predictable and many interruptions are essential for proper patient care. Recognizing this, commentators have called for research to analyze the causes and effects of interruptions, rather than attempting to categorically prevent interruptions. This study, conducted in an academic emergency department, contributes to our understanding of how interruptions influence patient care by examining the effect of interruptions on several specific nursing tasks. Interventions that were interrupted took longer than uninterrupted tasks, and interruptions were a significant contributor to overall nursing workload. Patients and families were the most frequent source of interruptions, demonstrating that simply implementing interventions to prevent interruptions could cause unintended consequences. The state of patient safety in the emergency department, including the role of interruptions, is discussed in a past AHRQ WebM&M perspective.
Mentis HM, Chellali A, Manser K, et al. Surg Endosc. 2016;30:1713-24.
This systematic review found that equipment and procedural distractions were the most severe distraction events during surgery, but irrelevant conversation and movement were the most frequent. This underscores the need to reduce distractions and incorporate management of distractions into surgical education.
Tubbs-Cooley HL, Pickler RH, Younger JB, et al. J Adv Nurs. 2015;71:813-24.
This study surveyed nurses in neonatal intensive care units about missed nursing care. As in other care settings, missed nursing care is significant, and reasons include interruptions, urgent patient situations, and increases in patient volume. This finding underscores the need to enhance nursing workflow to prevent errors of omission.
Monteiro SD, Sherbino JD, Ilgen JS, et al. Acad Med. 2015;90:511-517.
This study used written medical cases to examine whether simulated time pressure or interruptions affect diagnostic accuracy among resident and attending emergency medicine physicians. While the experienced physicians answered the questions more quickly and accurately compared to resident physicians, diagnostic accuracy was not compromised by time pressure or interruptions for either group in this study.