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 25 Results

Quality and Safety Considerations in Intensity Modulated Radiation Therapy: An ASTRO Safety White Paper Update.

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Moran JM, Bazan JG, Dawes SL, et al. Pract Radiat Oncol. 2023;13:203-216.

Safety risks are present in oncology radiation therapy. This recommendation builds on existing intensity modulated radiation therapy (IMRT) standards to highlight the importance of interdisciplinary engagement, training, and technology implementation to ensure high quality, safe IMRT is delivered to patients.

Quality improvement initiative to decrease central line-associated bloodstream infections during the COVID-19 pandemic: a "zero harm" approach.

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Redstone CS, Zadeh M, Wilson M-A, et al. J Patient Saf. 2023;19:173-179.

Previous research has found that central line-associated blood stream infections (CLABSIs) increased during the COVID-19 pandemic. This article describes the development, implementation, and evaluation of a quality improvement initiative (QI) at one community health system in Canada to reduce CLABSIs between July 2019 and May 2022. The QI initiative included changes in six areas – organizational oversight and accountability, education and training, standardized central line processes, optimized central line equipment, improving data and reporting, and fostering a culture of safety. Over the study period, CLABSIs were reduced by 51% and the use of both central line insertion checklists and central line capped lumens increased.

The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis

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Patient Safety Innovation March 15, 2023

During a time of unprecedented patient volume and clinical uncertainty, a diverse team of health system administrators and clinicians within the University of Pennsylvania Health System quickly investigated, updated, and disseminated airway management protocols after several airway safety incidents occurred among COVID-19 patients who were mechanically ventilated. Based on this experience, the team created the I-READI framework as a guide for healthcare systems to prepare for and quickly respond to quality and safety crises.¹

Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation

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WebM&M Case March 15, 2023

A 72-year-old man was diagnosed with COVID-19 pneumonia and ileus, and admitted to a specialized COVID care unit. A nasogastric tube (NGT) was placed, supplemental oxygen was provided, and oral feedings were withheld. Early in his hospital stay, the patient developed hyperactive delirium and pulled out his NGT. Haloperidol was ordered for use as needed (“prn”) and the nurse was asked to replace the NGT and confirm placement by X-ray. The bedside and charge nurses had difficulty placing the NGT and the X-ray confirmation was not done.

Causes of adverse events in home mechanical ventilation: a nursing perspective.

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Lipprandt M, Liedtke W, Langanke M, et al. BMC Nurs. 2022;21:264.

Hospital-level care at home can reduce cost and hospital readmissions, but adverse events still occur at levels similar to hospitals. This study explored adverse events related to home mechanical ventilation (HMV), in order to categorize causes and recommend solutions. Interventions for nurses (e.g., checklists) and manufacturers (e.g., alarm design) may improve HMV.

A retrospective review of serious surgical incidents in 5 large UK teaching hospitals: a system-based approach.

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Serou N, Slight RD, Husband AK, et al. J Patient Saf. 2022;18:358-364.

Operating rooms are high-risk healthcare settings. This study reviewed serious surgical incidents occurring at large teaching hospitals in one National Health Service (NHS) trust. The authors outline several possible contributing factors (i.e., equipment and resource factors, team factors, work environment factors, and organizational and management factors) discuss recommendations for safer care.

Improving peripherally inserted central catheter appropriateness and reducing device-related complications: a quasiexperimental study in 52 Michigan hospitals.

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Chopra V, O'Malley M, Horowitz J, et al. BMJ Qual Saf. 2022;31:23-30.

Peripherally inserted central catheters (PICC) represent a key source of preventable harm. Using the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC), the authors sought to determine if the appropriateness of PICC use decreased related medical complications including catheter occlusion, venous thromboembolism, and central line-associated bloodstream infections. Use of MAGIC in 52 Michigan hospitals increased appropriate use of PICC lines and decreased medical complications. In a 2019 PSNet Perspective, Dr. Vineet Chopra described the development and implementation of MAGIC in Michigan hospitals.

EMS crews brought patients to the hospital with misplaced breathing tubes. None of them survived

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Arditi L. Peoples Public Radio. December 3, 2019.

Emergency medical services are often provided under chaotic circumstances that may contribute to failure. This story highlights a series of esophageal intubation errors and efforts to minimize this “never event” across the state of Rhode Island. Improvement strategies discussed include practice restrictions for EMT personnel and use of less invasive, less risky processes to provide oxygen as an alternative to intubation, which may reduce esophageal intubation errors

Reducing three infections across cardiac surgery programs: a multisite cross-unit collaboration.

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Chang BH, Hsu Y-J, Rosen MA, et al. Am J Med Qual. 2020;35:37-45.

Preventing health care–associated infections remains a patient safety priority. This multisite study compared rates of central line–associated bloodstream infections, surgical site infections, and ventilator-associated pneumonia before and after implementation of a multifaceted intervention. Investigators adopted the comprehensive unit-based safety program, which emphasizes safety culture and includes staff education, identification of safety risks, leadership engagement, and team training. Central line–associated bloodstream infections and surgical site infections initially declined, but rates returned to baseline in the third year. They were unable to measure differences in ventilator-associated pneumonia rates due to a change in the definition. These results demonstrate the challenge of implementing and sustaining evidence-based safety practices in real-world clinical settings. A past PSNet interview discussed infection prevention and patient safety.

New mother number 14.

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Sangarlangkarn A. Healthc (Amst). 2019;7:31-32.

Rigid adherence to protocols may detract from safety when unexpected critical events occur that require deviation from the standard process. This commentary explores insights from a physician, both as a clinician and as a new mother, when health care staff failed to effectively consider patient concerns and knowledge in understanding and treating the cause of postlabor pain. The patient identified the cause and requested appropriate treatment, but nurses consulted protocols for pain after labor and only offered pain medications, which might have exacerbated the problem. The author calls for clinician autonomy to recognize when standardization is not appropriate and how to address individual patient needs.

Which Line: Ordering Provider or Proceduralist?

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WebM&M Case March 1, 2019

A woman with multiple myeloma required placement of a central venous catheter for apheresis. The outpatient oncologist intended to order a nontunneled catheter via computerized provider order entry but accidentally ordered a tunneled catheter. The interventional radiologist thought the order was unusual but didn't contact the oncologist. A tunneled catheter was placed without complications. When the patient presented for apheresis, providers recognized the wrong catheter had been placed, and the patient underwent an additional procedure.

Performing an inadvertent procedure.

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Gupta A, Jain S, Croft C. JAMA. 2019;321:504-505.

The authors present a case in which an unnecessary procedure was incorrectly performed on a patient who had opted to pursue hospice care. They highlight factors contributing to the error including those related to use of the electronic health record.

Training induces cognitive bias: the case of a simulation-based emergency airway curriculum.

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Park C, Stojiljkovic L, Milicic B, et al. Simul Healthc. 2014;9:85-93.

This educational study found that anesthesiology residents were more likely to initiate an airway technique for which they had received simulation training, even if another technique (for which they received didactic training) would have been more appropriate. This finding demonstrates how training may inadvertently introduce cognitive bias.

The Unfamiliar Catheter

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WebM&M Case March 1, 2013

While drawing labs on a woman admitted after a lung transplant, a nurse failed to clamp the patient's large-bore central line, allowing air to enter the catheter. The patient suffered a cerebral air embolism and was transferred to the ICU for several days.

CVC Placement: Speak Now or Do Not Use the Line

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WebM&M Case February 1, 2013

A woman found unresponsive at home presented to the ED via ambulance. The cardiology team used the central line placed during resuscitation to deliver medications and fluids during pacemaker insertion. Hours later, a chest radiograph showed whiteout of the right lung, and clinicians realized that the tip of the line was actually within the lung.

Are We Pushing Graduate Nurses Too Fast?

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WebM&M Case March 1, 2011

While caring for a complex patient in the surgical intensive care unit, a nurse incorrectly set up the continuous renal replacement therapy (CRRT) machine, raising questions about how new nurses should be trained in high-risk procedures.

Dangerous Dialysis

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WebM&M Case October 1, 2010

A man with end-stage renal disease on hemodialysis was dialyzed with equipment that had been inappropriately reused, exposing the patient to another patient's blood numerous times.

Preventable morbidity at a mature trauma center.

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Teixeira PGR, Inaba K, Salim A, et al. Arch Surg. 2009;144(6):536-541.

Patient safety in trauma poses unique challenges given the acuity of the patients and the need for rapid assessment in delivering life-saving care. This study analyzed more than 2500 complications discussed at morbidity and mortality (M&M) conferences to characterize their preventability and clinical relevance. Investigators discovered that the complications ripe for quality improvement initiatives included unintended extubations, surgical technical failures, missed injuries, and intravascular catheter-related complications. An invited critique [see link below] reflects on the study's findings and points out the challenges in reporting performance data without needed standardization. A past AHRQ WebM&M commentary discussed the systematic assessment of trauma patients in the context of a missed patient injury.

Specialty-based, voluntary incident reporting in neonatal intensive care: description of 4846 incident reports.

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Snijders C, van Lingen RA, Klip H, et al. Arch Dis Child Fetal Neonatal Ed. 2009;94:F210-5.

Incident reporting systems are one mechanism for hospitals to both identify and potentially prevent adverse events, although they have frequently failed to meet those expectations. This study describes findings from a voluntary system that produced a significant increase in reported neonatal events, many of which were associated with patient morbidity.

Interference between CT and Electronic Medical Devices.

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Center for Devices and Radiological Health; CDER; Food and Drug Administration; FDA.

This website alerts clinicians and patients to risks for patient harm associated with implanted electronic medical devices, such as insulin infusion pump and pacemakers, when x-rays are used during CT examinations.

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