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.
Tsilimingras D, Natarajan G, Bajaj M, et al. J Patient Saf. 2022;18:462-469.
Post-discharge events, such as medication errors, can occur among pediatric patients discharged from inpatient settings to home. This prospective cohort, including infants discharged from one level 4 NICU between February 2017 and July 2019, identified a high risk for post-discharge adverse events, (including procedural complications and adverse drug events) and subsequent emergency department visits or hospital readmissions. Nearly half of these events were due to management, therapeutic, or diagnostic errors and could have been prevented.
Dregmans E, Kaal AG, Meziyerh S, et al. JAMA Netw Open. 2022;5:e2218172.
Inappropriate antibiotic prescribing can result in patient harm and costly antibiotic-resistant infections. Health record review of 1,477 patients admitted from the emergency department for suspected bacteremia infection revealed that 11.6% were misdiagnosed at infection site, and 3.1% did not have any infection. Misdiagnosis was not associated with worse short-term clinical outcomes but was associated with potentially inappropriate broad-spectrum antibiotic use.
Burrus S, Hall M, Tooley E, et al. Pediatrics. 2021;148:e2020030346.
Based on analysis of four years of data submitted to the Child Health Patient Safety Organization (CHILDPSO), researchers sought to identify types of serious safety events and contributing factors. Three main groups of serious safety events were identified: patient care management, procedural errors, and product or device errors. Contributing factors included lack of situational awareness, process failures, and failure to communicate effectively.
Urquhart A, Yardley S, Thomas E, et al. J R Soc Med. 2021;114:563-574.
This mixed-methods study analyzed patient safety incident reports between 2005-2015 to characterize the most frequently reported incidents resulting in severe harm or death in acute medical units. Of the 377 included reports, diagnostic errors, medication-related errors, and failure to monitor patient incidents were most common. Patients were at highest risk during handoffs and transitions of care. Lack of active decision-making during admission and communication failures were the most common contributors to incidents.
Simulation is a recognized technique to educate and plan to improve care processes and safety. This pair of special issues highlights the use of simulation in nursing and its value in work such as communication enhancement, minority population care, and patient deterioration.
Much of the evidence about preventable harm in patients with psychiatric illnesses is limited to inpatient psychiatric facilities. This case-control study explores patient-related factors that place patients at an increased risk for patient safety incidents in primary or emergency care. While differences in income, education, and foreign background had some association with preventable harm, researchers found that psychiatric illness nearly doubled the risk of preventable harm among both emergency and primary care patients, with nearly half (46%) of harm attributable to diagnostic errors.
Cheung R, Roland D, Lachman P. Arch Dis Child. 2019;104:1130-1133.
Children are vulnerable to delayed or missed diagnosis, infections, and medication errors. This commentary summarizes the current state of pediatric patient safety improvement efforts in the United Kingdom and emphasizes the importance of systems approaches to safety. The authors highlight huddles and pediatric early warning systems as two tactics that improve the reliability of communication to address the complex needs of pediatric patients.
Verghese A, Charlton B, Kassirer JP, et al. Am J Med. 2015;128:1322-4.e3.
There is a growing concern that lack of emphasis on performing the physical examination will lead to diagnostic errors. This study asked physicians to report cases of oversights in the physical examination which contributed to missed or delayed diagnosis. The majority of incidents reported were errors of omission in which the entire examination was not performed, with smaller proportions reporting misinterpretation or failure to conduct a specific aspect of the examination. Respondents reported delays and failures in diagnosis as well as significant instances of over-treatment and increased cost. This underscores the need to emphasize the importance of the physical examination in medical education and practice as a patient safety strategy. The lead author, Dr. Abraham Verghese, discussed the importance of physical examination in a past AHRQ WebM&M interview.
Southwick FS, Cranley NM, Hallisy JA. BMJ Qual Saf. 2015;24:620-9.
This study analyzed data from an internet-based reporting system that enabled patients and families to describe adverse events. Respondents reported missed and delayed diagnoses, treatment errors, procedural complications, health care–associated infections, and adverse drug events. Most participants did not experience prompt error disclosure but instead faced a denial of responsibility and secretive behavior, which they related to subsequent mistrust. To prevent adverse events, patients and family members suggested using systems approaches (such as universal handwashing and other infection control measures), improving care transitions between providers, ensuring supervision of trainees, and partnering with patients and families for shared decision-making. These findings underscore the importance of error disclosure, effective communication, and allowing patients to report adverse events in order to enhance safety.
Filice GA, Drekonja DM, Thurn JR, et al. Infect Control Hosp Epidemiol. 2015;36:949-56.
Overuse of antibiotics is a major factor in the development of certain types of health care–associated infections. This retrospective study found that unnecessary antibiotic use was often a result of diagnostic error, particularly in patients who were empirically treated for urinary tract infections without clear diagnostic evidence. The results of this study imply that addressing diagnostic uncertainty should be a component of antimicrobial stewardship programs.
Matlow AG, Baker R, Flintoft V, et al. CMAJ. 2012;184:E709-718.
Hospitalized children are particularly vulnerable to specific types of errors, such as medication errors. This Canadian study used a trigger tool approach to estimate the frequency of all types of adverse events in hospitalized children, and found that nearly 1 in 10 pediatric patients suffers an adverse event while hospitalized. This prevalence is similar to classic studies performed in adult populations. Preventable adverse events, which accounted for approximately half of all events, were particularly common in children undergoing surgery or requiring intensive care. Diagnostic errors also accounted for a significant proportion of preventable adverse events. A preventable error in a critically ill 8-month-old child is discussed in an AHRQ WebM&M commentary.
Murff HJ, FitzHenry F, Matheny ME, et al. JAMA. 2011;306:848-55.
Many adverse event identification methods cannot detect errors until well after the event has occurred, as they rely on screening administrative data or review of the entire chart after discharge. Electronic medical records (EMRs) offer several potential patient safety advantages, such as decision support for averting medication or diagnostic errors. This study, conducted in the Veterans Affairs system, reports on the successful development of algorithms for screening clinicians' notes within EMRs to detect postoperative complications. The algorithms accurately identified a range of postoperative adverse events, with a lower false negative rate than the Patient Safety Indicators. As the accompanying editorial notes, these results extend the patient safety possibilities of EMRs to potentially allow for real time identification of adverse events.
Wittich CM, Lopez-Jimenez F, Decker LK, et al. J Gen Intern Med. 2011;26:293-8.
Reflection, or thinking about thinking, is often used as a technique to encourage learning from adverse events. This study describes the development and pilot testing of a case-based system to encourage and measure reflection among faculty physicians at an academic medical center.
Dückers M, Faber M, Cruijsberg J, et al. Med Care Res Rev. 2009;66:90S-119S.
Improving patient safety requires development of a culture of safety and transformation into a learning organization—one that has the capacity to rapidly address problems through information sharing and learning from past experience. In this systematic review, the authors characterize the published literature on organizational safety programs, and summarize published data on error detection methods (such as incident reporting systems), error analysis, and systems to mitigate and reduce specific errors (such as diagnostic errors and medication errors). The review is limited by publication bias (the preferential publication of studies with positive results) and the descriptive nature of most studies, reducing the generalizability of these studies for other organizations. An AHRQ WebM&M perspective discusses organizational approaches to safety improvement in academic and community settings.
Smits M, Groenewegen PP, Timmermans DRM, et al. BMC Emerg Med. 2009;9:16.
Emergency department (ED) patients are particularly vulnerable to adverse events, and a prior study of closed malpractice claims implicated systems factors such as poor teamwork in adverse patient outcomes. This study used root cause analysis of incident reports to identify the types and causes of errors and unanticipated events in the ED. Incidents included poor communication and teamwork, particularly with other departments, but medication errors and diagnostic errors were also noted. The authors recommend that organizations integrate the ED into hospital-wide safety improvement efforts.
Levtzion-Korach O, Alcalai H, Orav EJ, et al. J Patient Saf. 2009;52:9-15.
The limitations of standard incident reporting systems have been well documented. Although ubiquitous and relatively easy to use, such systems detect only a fraction of adverse events, are underused by physicians, and yield data that often are not analyzed or disseminated promptly. This analysis of data from a commercial, web-based system at an academic hospital confirms some prior concerns, but the authors were able to demonstrate that rapid review of reports resulted in specific system changes to improve workflow and safety. A prior article presented a framework for using incident reporting data to improve patient safety.
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