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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 817 Results
WebM&M Case February 1, 2023

A 5-day old male infant was admitted to the pediatric intensive care unit (PICU) and underwent surgery to correct a congenital heart defect. The patient’s postoperative course was complicated Staphylococcus aureus bacteremia and other problems, requiring venoarterial extracorporeal membrane oxygenation (VA-ECMO) and subsequent cardiac procedures.

Cresham Fox S, Taylor N, Marufu TC, et al. Intensive Crit Care Nurs. 2022;Epub Dec 3.
While many hospitals have rapid response teams (RRT) which can be activated by clinicians, only a few hospitals have also implemented programs which allow patients and families to activate RRT. This review identified 6 articles (5 interventions) with family-activated RRT in pediatric hospitals. The authors of the review conclude that family-activated RRT is a key component to family engagement and enhancing patient safety. Only one intervention was also available in a non-English language, which should be considered in future interventions.
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.
Almqvist D, Norberg D, Larsson F, et al. Intensive Crit Care Nurs. 2022;74:103330.
Interhospital transfers pose a serious risk to patients. In this study, nurse anesthetists and intensive care nurses described strategies to ensure safe transport for patients who are intubated or who may require intubation. Strategies include clear and adequate communication between providers prior to transport, stabilizing and optimizing the patient’s condition, and ensuring that appropriate drugs and equipment are prepared and available.
WebM&M Case December 14, 2022

A 65-year-old man with metastatic liver disease presented to the hospital with worsening abdominal pain after a partial hepatectomy and development of a large ventral hernia. Imaging studies revealed perforated diverticulitis. A goals-of-care discussion was led by the palliative care service; the patient and his designated decision-makers chose to pursue non-operative management of diverticulitis.

Henry Basil J, Premakumar CM, Mhd Ali A, et al. Drug Saf. 2022;45:1457-1476.
Medication administration errors (MAEs) are thought to be common in neonatal intensive care units (NICUs). This systematic review estimated that the pooled prevalence of MAEs among patients in NICU settings ranged from 59% to 65%. The review highlights both active failures (e.g., similar drug packaging or names) and latent failures (e.g., noisy environments, inaccurate verbal or written orders) contributing to MAEs.
Pun BT, Jun J, Tan A, et al. Am J Crit Care. 2022;31:443-451.
Team collaboration is an essential part of ensuring patient safety in acute care settings. This survey of care team members (including nurses, physicians, pharmacists, respiratory therapists, and rehabilitation therapists) assessed teamwork and collaboration across 68 intensive care units (ICUs). Teamwork and work environment were rated favorably but care coordination and meaningful recognition were rated least favorably.
Rosen A, Carter D, Applebaum JR, et al. J Patient Saf. 2022;18:e1219-e1225.
The COVID-19 pandemic had wide-ranging impacts on care delivery and patient safety. This study examined the relationship between critical care clinician experiences related to patient safety during the pandemic and COVID-19 caseloads during the pandemic. Findings suggest that as COVID-19 caseloads increased, clinicians were more likely to perceive care as less safe.
Ibrahim M, Szeto WY, Gutsche J, et al. Ann Thorac Surg. 2022;114:626-635.
Reports of poor care in the media or public reporting systems can serve as an impetus to overhauling hospitals or hospital units. After several unexpected deaths and a drop in several rating systems, this cardiac surgery department launched a comprehensive quality improvement review. This paper describes the major changes made in the department, including role clarity and minimizing variation in 24/7 staffing.
Kam AJ, Gonsalves CL, Nordlund SV, et al. BMC Emerg Med. 2022;22:152.
Debriefing after significant clinical events facilitates team-based communication, learning, and support. This study compared two post-resuscitation debriefing tools (Debriefing In Situ Conversation after Emergent Resuscitation Now [DISCERN] and Post-Code Pause [PCP]) following any intubation, resuscitation, or serious/unanticipated patient outcome in a children’s hospital. PCP was found to provide more emotional support and clinical learning, but there were no differences in the remaining categories.

ISMP Medication Safety Alert! Acute care edition. October 6, 2022;27(20):1-5.

Patient resuscitation is a complex, distinct, team activity that can be prone to error. Pharmacists involved in codes reported concerns including errors with high-alert medications and communication gaps. Improvement recommendations focused on preparation for, actions during and post code phrases which included standardizing the practice of including pharmacists in codes, simulation, and regular debriefing.
Liu SI, Shikar M, Gante E, et al. Crit Care Nurse. 2022;42:33-43.
Lack of communication between providers can contribute to failure to rescue. Following a series of deaths due in part to not identifying clinical deterioration in a timely manner and/or not escalating care, this surgical intensive care unit (SICU) implemented an interdisciplinary quality improvement intervention. The intervention consisted of educating nurses on conditions necessitating escalation, multidisciplinary rounds with night staff, and an escalation document in the electronic health record (EHR).
Mohanna Z, Kusljic S, Jarden R. Aust Crit Care. 2022;35:466-479.
Many types of interventions, such as education, technology, and simulations, have been used to reduce medication errors in the intensive care setting. This review identified 11 studies representing six intervention types; three of the six types showed improvement (prefilled syringe, nurses’ education program, and the protocolized program logic form) while the other three demonstrated mixed results.
Hebballi NB, Gupta VS, Sheppard K, et al. J Patient Saf. 2022;18:e1021-e1026.
Handoffs from one care team to another present significant risks to the patient if essential patient information is not shared or understood by all team members. Stakeholders at this children’s hospital developed a structured tool for handoff between surgery and pediatric or neonatal intensive care units. Transfer of information and select patient outcomes improved, handoff time was unchanged, and attendance by all team members increased.
Schilling S, Armaou M, Morrison Z, et al. PLoS ONE. 2022;17:e0272942.
Effective teamwork is critical in acute and intensive care settings. This systematic review of reviews and thematic analysis identified four key factors that frame the evidence on interprofessional teams in acute and intensive care settings – (1) team internal procedures and dynamics, such as cohesion, organizational culture, and leadership influence; (2) communicative processes; (3) organizational and team-extrinsic influences, such as team composition, hierarchy, and interprofessional dynamics, and; (4) team outcomes, including both patient and staff outcomes.
Wahl K, Stenmarker M, Ros A. BMC Health Serv Res. 2022;22:1101.
Patient safety huddles generally use a Safety-I approach to learn from errors and increase team awareness about safety threats. This mixed-methods study found that patient safety huddles including a focus on learning from what works well (Safety-II) may be beneficial to healthcare organizations, particularly if they can purposely focus on learning from both negative and positive experiences.
Stayt LC, Merriman C, Bench S, et al. J Adv Nurs. 2022;78:3371-3384.
The COVID-19 pandemic dramatically changed healthcare delivery across all settings. This qualitative study explored perceptions of patient safety in intensive care among nurses redeployed to intensive care settings during the pandemic. Nurses reported increases in patient safety risks during the pandemic, which were largely attributed to changes in nursing skill mix and poor continuity of care.
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.
WebM&M Case August 31, 2022

A 2-year-old girl presented to her pediatrician with a cough, runny nose, low grade fever and fatigue; a nasal swab for SARS-CoV-2 and influenza was negative and lung sounds were clear. The patient developed a fever and labored breathing and was taken to the Emergency Department (ED) before being admitted to the hospital. She developed respiratory distress and clinically worsened over time until she developed respiratory failure requiring air transportation to the pediatric intensive care unit at a children’s hospital.