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 1729 Results

Surgical site infection prevention: a review.

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Seidelman JL, Mantyh CR, Anderson DJ. JAMA. 2023;329:244-252.

Surgical site infections (SSIs) remain a significant cause of preventable post-operative morbidity and mortality. This narrative review summarizes modifiable and nonmodifiable patient-related factors. It also evaluates modifiable operation-related factors associated with surgical site infections, and highlights six pre-, intra-, and postoperative strategies to reduce surgical site infections, including use of the WHO surgical safety checklist.

A deadly epidural, delivered by a doctor with a history of mistakes.

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Goldstein J. New York Times. January 23, 2023.

Active errors are evident when they occur, yet systemic weaknesses, if not addressed, allow them to repeat. This story examines poor epidural methods of one clinician that coincided with lack of organizational practitioner monitoring, unequitable maternal care for black women and clinician COVID fatigue to contribute to patient death.

The impact of TeamSTEPPS training on obstetric team attitudes and outcomes on the labor and delivery unit of a regional perinatal center.

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Kwon CS, Duzyj C. Am J Perinatol. 2022;Epub Dec 30.

Effective teamwork is critical for patient safety and numerous training strategies exist for improving team dynamics. The labor and delivery unit of an American hospital offered Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) training to all physicians and nurses on the ward, and assessed perceptions of teamwork and safety both before and six months after training. Results were mixed, and physician and nurse perceptions of safety significantly differed.

Hospital-Acquired Diabetic Ketoacidosis.

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WebM&M Case February 1, 2023

This WebM&M highlights two cases of hospital-acquired diabetic ketoacidosis (DKA) in patients with type 1 diabetes. The commentary discusses the role of the inpatient glycemic team to assist with diabetes management, the importance of medication reconciliation in the emergency department (ED) for high-risk patients on insulin, and strategies to empower patients and caregivers to speak up about medication safety.

Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure.

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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.

The safety of inpatient health care.

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Bates DW, Levine DM, Salmasian H, et al. New Engl J Med. 2023;388:142-153.

An accurate understanding of the frequency, severity, and preventability of adverse events is required to effectively improve patient safety. This study included review of more than 2,800 inpatient records from 11 American hospitals with nearly one quarter having at least one preventable or not preventable adverse event. Overall, approximately 7% of all admissions included at least one preventable event and 1% had a severity level of serious or higher.

Exploring nursing-sensitive events in home healthcare: a national multicenter cohort study using a trigger tool.

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Nilsson L, Lindblad M, Johansson N, et al. Int J Nurs Stud. 2022;138:104434.

Nurse-sensitive outcomes are important indicators of nursing safety. In this retrospective study of 600 patient records from ten Swedish home healthcare organizations, researchers found that 74% of patient safety incidents were classified as nursing-sensitive and that the majority of those events were preventable. The most common types of nursing-sensitive events were falls, pressure injuries, healthcare-associated infections, and incidents related to medication management.

Incidence and characteristics of adverse events in paediatric inpatient care: a systematic review and meta-analysis.

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Dillner P, Eggenschwiler LC, Rutjes AWS, et al. BMJ Qual Saf. 2022;Epub Dec 26.

Retrospective error detection methods, such as trigger tools, are widely used to uncover the incidence and characteristics of adverse events (AE) in hospitalized children. This review sought AEs identified by three trigger tools: Global Trigger Tool (GTT), the Trigger Tool (TT) or the Harvard Medical Practice Study (HMPS) method. Results from the trigger tools were widely variable, similar to an earlier review in adult acute care, and suggest the need for strengthening reporting standards.

Interventions to increase patient safety in long-term care facilities-umbrella review.

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Świtalski J, Wnuk K, Tatara T, et al. Int J Environ Res Public Health. 2022;19:15354.

Improving patient safety in long-term care facilities is an ongoing challenge. This systematic review identified three types of interventions that can improve safety in long-term care facilities – (1) promoting safety culture, (2) reducing occupational stress and burnout, and (3) increasing medication safety.

Patient safety performance: reversing recent declines through shared profession-wide system-level solutions.

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James BC, Savitz L, Fairbanks RJ, et al. NEJM Catalyst. Epub Dec 12, 2022.

The COVID-19 pandemic revealed fractures in health care systems worldwide. The authors advocate for enhanced use of systems-focused and organization-centric strategies to improve patient safety through universal application of best practices.

A multi-site assessment of inpatient safety event rates during the coronavirus disease 2019 pandemic.

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Pollock BD, Dykhoff HJ, Breeher LE, et al. Mayo Clin Proc Innov Qual Outcomes. 2023;7:51-57.

The COVID-19 pandemic dramatically impacted healthcare delivery and raised concerns about exacerbating existing patient safety challenges. Based on incident reporting data from three large US academic medical centers from January 2020 through December 2021, researchers found that patient safety event rates did not increase during the COVID-19 pandemic, but they did observe a relationship between staffing levels during the pandemic and patient safety event rates.

Quality and Safety in Health Care.

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Harolds JA, Harolds LB. Clin Nucl Med. 2015–2023.

This monthly commentary explores a wide range of subjects associated with patient safety, such as infection prevention, surgical quality improvement, and high reliability organizations.

Balancing safety, comfort, and fall risk: an intervention to limit opioid and benzodiazepine prescriptions for geriatric patients.

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Bloomer A, Wally M, Bailey G, et al. Geriatr Orthop Surg Rehabil. 2022;13:215145932211256.

Opioid use by older adults increases the risk of falls. This study examined electronic health record data to determine the proportion of older adults presenting to the emergency room or urgent care due to a fall who receive an opioid prescription, particularly those with at least one risk factor for misuse. Nearly one third of patients received a prescription for an opioid and/or benzodiazepine, and 11% had at least one risk factor for misuse.

Sources of nurse-sensitive inpatient safety improvement.

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Dynan L, Smith RB. Health Serv Res. 2022;57:1235-1246.

Nurses play a critical role in ensuring patient safety, and prior research has shown that better nurse-staffing ratios and nurse engagement can improve mortality rates. This study of nearly 300 Florida acute-care hospitals evaluated the effect of expenditures on continuing nurse education staffing ratios of several AHRQ Patient Safety Indicators (PSI). Increased spending on both improved outcomes in catheter-related blood stream infections, pressure ulcers, and deep vein thrombosis.

Strategies for a safe interhospital transfer with an intubated patient or where readiness for intubation is needed: a critical incidents study.

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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.

A recent two-fold increase in medical adverse event deaths among US inpatients.

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Oura P, Sajantila A. J Public Health Res. 2022;11:227990362211399.

Although patient safety is a national priority, preventable harm among patients remains high. After analyzing national death certificate data from 1999 through 2019, researchers in this study found that medical adverse events were listed as the underlying cause of death in 0.24% of deaths. From 2014 to 2019, researchers identified a nearly 16% annual increase in deaths attributed to adverse events, primarily driven by procedure-related adverse events and possibly related to the implementation of ICD-10 in 2015.

Barriers and facilitators to reporting medical device-related pressure ulcers: a qualitative exploration of international practice.

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Crunden EA, Worsley PR, Coleman SB, et al. Int J Nurs Stud. 2022;135:104326.

Hospital-acquired pressure ulcers, categorized as a never event, are underreported, particularly when related to medical devices. Interviews with experts in hospital-acquired pressure ulcers revealed four domains related to reporting: 1) individual health professional factors, 2) professional interactions, 3) incentives and resources, and 4) capacity for organizational change. Teamwork, openness, and feedback were seen as the main facilitators to reporting, and financial consequences was a contributing barrier.

Patient safety culture as a space of social struggle: understanding infection prevention practice and patient safety culture within hospital isolation settings - a qualitative study.

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Hunt J, Gammon J, Williams S, et al. BMC Health Serv Res. 2022;22:1446.

Isolation for infection prevention and control may result in unintended consequences for patient safety. Using focus groups at two hospitals, this study explored healthcare staff understanding of infection prevention practices and patient safety culture within insolation settings. Thematic analysis highlights the importance of engaged leadership, appropriate staffing, teamwork, and prioritization of patient-centered care in achieving a culture of safety and improvements in infection prevention.

Using community detection techniques to identify themes in COVID-19-related patient safety event reports.

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Boxley C, Krevat SA, Sengupta S, et al. J Patient Saf. 2022;18:e1196-e1202.

COVID-19 changed the way care is delivered to hospitalized patients and resulted in new categories and themes in patient safety reporting. This study used machine learning to group of more than 2,000 patient safety event (PSE) reports into eight clinically relevant themes, including testing delays, diagnostic errors, pressure ulcers, and falls.

Her child was stillborn at 39 weeks. She blames a system that doesn’t always listen to mothers.

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Eldeib D. ProPublica. November 13, 2022.

Pregnancy is recognized as a high-risk condition for both mother and infant. This news story examines the potential for stillbirth and its preventability. Lack of respect for the concerns of mothers, inadequate attention to research, and poor patient education are discussed as contributors to stillbirth.

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