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.
Patel S, Robertson B, McConachie I. Anaesthesia. 2019;74:904-914.
Medication administration mistakes can result in serious patient harm. This review explored human factors that contribute to spinal anesthesia administration errors. The authors documented organizational, supervisory, system, and individual factors that contributed to errors. They recommend strategies to prevent such incidents, including the use of double checks and improved labeling practices.
Chew KS, van Merrienboer JJG, Durning SJ. BMC Med Educ. 2019;19:18.
Metacognition is an approach to enhance diagnostic thinking. This study used focus groups to assess physicians' and medical students' impressions of a metacognitive diagnostic checklist. Participants found the checklist to be applicable and usable, and the authors conclude that it should be tested in a clinical setting.
Hsu K-Y, DeLaurentis P, Bitan Y, et al. J Patient Saf. 2019;15:e8-e14.
Smart infusion pumps store drug safety information, but this data must be periodically updated. This study demonstrated significant delays in updating the drug information for smart infusion pumps. These delays resulted in failure to alert for two high-risk medication cases, but neither case led to patient harm.
George D, Hassali MA, Hss A-S. JMIR Hum Factors. 2018;5:e12232.
This mixed-methods study examined the usability of a mobile application for reporting medication errors at a referral hospital in Malaysia. Usability improved over each of the three cycles of testing and iterative redesign, but physician and nurse testers expressed concern about whether the safety culture supported reporting.
Rahimi R, Kazemi A, Moghaddasi H, et al. Chemotherapy (Los Angel). 2018;63:162-171.
Computerized provider order entry (CPOE) is an effective tool for reducing chemotherapy medication errors. This systematic review of CPOE and clinical decision support systems for chemotherapy administration revealed a recent proliferation in the scope and complexity of both types of electronic tools. A recent WebM&M commentary examines how to prevent and respond to catastrophic chemotherapy errors.
Chen C, Kan T, Li S, et al. Am J Emerg Med. 2016;34.
Process and procedure consistency contributes to safe, highly reliable health care. This review examined the literature on the use of standard operating procedures and checklists in prehospital emergency medicine and found encouraging results on safety improvements associated with such interventions in this practice environment.
Suzuki S, Chan A, Nomura H, et al. J Oncol Pract. 2017;23:18-25.
Chemotherapy is known to be a high-risk treatment that requires specific safety protocols. This study found that pharmacy checks of physician chemotherapy orders entered via computer order entry do uncover errors. The authors conclude that electronic prescribing is not sufficient to ensure safe chemotherapy prescription and recommend maintaining the role of oncology pharmacists.
Limited data exists regarding how pharmacies can prevent look-alike, sound-alike medication errors. This study found that several methods of text enhancement—including boldface type and "tall man" lettering—improved the accuracy of drug identification for look-alike drugs.
Corbally MT, Tierney E. Int J Pediatr. 2014;2014:791490.
Many institutions are attempting to increase patient and family engagement in safety efforts. This report on integrating parents of children undergoing surgery into the completion of the WHO surgical safety checklist provides a helpful example of families being successfully incorporated into an existing safety program.
Chen K-H, Chen L-R, Su S. Qual Saf Health Care. 2010;19:138-43.
This Taiwanese study used root cause analysis to identify causal factors for falls in postpartum women, and used the findings to design a quality improvement intervention that significantly reduced the fall rate over a 6-month period.
Einav Y, Gopher D, Kara I, et al. Chest. 2010;137:443-9.
Improving perioperative safety requires optimal communication within the surgical team; however, classic studies have shown that teamwork in the operating room is often suboptimal. This study successfully improved communication and safety through creation of a structured preoperative briefing protocol for gynecologic and orthopedic procedures. The protocol required discussion of critical operative elements between the surgeons, anesthesiologists, and nurses prior to surgery. Checklists have been remarkably successful at reducing perioperative adverse events, and this protocol incorporated some elements of previously published perioperative checklists and The Joint Commission's Universal Protocol. However, the protocol used in this study focused on creating shared situational awareness among all team members, and did not explicitly mandate specific steps as in a checklist. An accompanying editorial discusses the cultural challenges that have accompanied attempts to improve surgical safety.
Arzy S, Brezis M, Khoury S, et al. J Eval Clin Pract. 2009;15:804-6.
Diagnostic errors frequently occur because of cognitive errors on the part of physicians. This study used case vignettes to vividly illustrate one specific cognitive error, the "framing effect," whereby a clinician places undue emphasis on a single (often extraneous) piece of information. Inclusion of a single misleading detail resulted in experienced clinicians making significantly more diagnostic errors. The process of meta-cognition, or "thinking about thinking," is often used to attempt to overcome this and other biases in clinical decision-making. An AHRQ WebM&M perspective explores issues related to cognitive errors in diagnosis.
This initiative provides a surgical safety checklist and related educational and training materials building on the Second Global Patient Safety Challenge vision to encourage international adoption of a core set of safety standards. Implementation of this World Health Organization’s checklist has resulted in dramatic reductions in surgical mortality and complications across diverse international hospitals. Surgical checklists have now become one of the clearest success stories in the patient safety movement, although some have described challenges to effective implementation. Dr. Atul Gawande discussed the history of checklists as a quality and safety tool in his book, The Checklist Manifesto: How to Get Things Right.
Sawamura K, Ito H, Yamazumi S, et al. Psychiatry Clin Neurosci. 2005;59:379-84.
The authors analyzed incident reports from Japanese long-term care psychiatric units to understand the relationship between environmental, organizational, and human factors elements of drug administration and how they affect the interception of errors.
Donchin Y, Gopher D, Olin M, et al. Crit Care Med. 1995;23:294-300.
This study investigates the nature of human errors in the intensive care unit (ICU), adopting approaches developed by human factors engineering. The methodology, referred to as task analysis, was used to interpret the activities around patients in a medical-surgical ICU. A team of specially trained nonmedical investigators observed daily activities, while physicians and nurses simultaneously reported any observed errors. Based on the pooled data, an estimated 1.7 errors per patient-day occurred, with nearly 2 severe or detrimental errors occurring in the ICU as a whole. The methods explored in this study represent a growing trend in improving safety, which is to better understand the true nature of errors in complex health care settings such as an ICU. The authors conclude that communication failures between physicians and nurses play a significant role in the described errors, a problem they emphasize should be amenable to intervention.
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