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 2347 Results

As cancer drug shortages grow, some doctors are forced to ration doses or delay care.

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Kopf M, Beck C. NBC News. May 26, 2023.

Lack of access to appropriate cancer medications can be particularly difficult for patients and clinicians. This news article discusses the current shortage of chemotherapy drugs, the psychological and physical harm potential in the situation and what should be done to improve medication supply.

Impact of a computerized physician order entry system on medication safety in pediatrics-The AVOID study.

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Wimmer S, Toni I, Botzenhardt S, et al. Pharmacol Res Perspect. 2023;11:e01092.

Computerized physician order entry (CPOE) systems can prevent medication ordering and dispensing errors. This pre-post study compared medication safety outcomes for paper-based prescribing versus CPOE-based prescribing among pediatric patients at one German hospital. The researchers found that CPOE implementation resulted in fewer potentially harmful medication errors.

Classification of health information technology safety events in a pediatric tertiary care hospital.

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Khan A, Karavite DJ, Muthu N, et al. J Patient Saf. 2023;19:251-257.

For incidents to be properly addressed, incident reports must be appropriately identified and categorized by safety managers. This study compared the categorization of incidents as involving health information technology (HIT) or not involving HIT by specialists trained in HIT and patient safety and safety managers trained in traditional methods of health safety. Safety managers only agreed with the HIT specialist classification 25% and 75% of the time on incidents involving or not involving HIT, respectively. Increased education for safety managers on the interaction of HIT and patient safety may result in better classification of HIT-related incidents.

Analysis of the nature and contributory factors of medication safety incidents following hospital discharge using National Reporting and Learning System (NRLS) data from England and Wales: a multi-method study.

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Alqenae FA, Steinke DT, Carson-Stevens A, et al. Ther Adv Drug Saf. 2023;14:204209862311543.

Medication errors and adverse drug events (ADE) are unfortunately common at hospital discharge. This study used the National Reporting and Learning System (NRLS) in England and Wales to identify contributing causes to medication errors and ADE. Patients over 65 were the most common age group and, of incidents with a stated level of harm, most did not result in any harm. Overall, most incidents occurred at the prescribing stage, but varied by patient age group. Most contributory factors were organizational (e.g., continuity of care between provider types), followed by staff, patient, and equipment factors.

Understanding medication safety involving patient transfer from intensive care to hospital ward: a qualitative sociotechnical factor study.

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Bourne RS, Jeffries M, Phipps DL, et al. BMJ Open. 2023;13:e066757.

Patients transitioning from the intensive care unit (ICU) to the general ward are vulnerable to medication errors. This qualitative study included medical staff and clinical pharmacists from hospital wards and ICUs to identify factors that contribute to medication safety or adverse events at times of transition. Lack of communication between provider types (e.g., nurse and pharmacist) and time pressure considerations had negative effects on medication safety. Ward rounds and safety culture had positive effects.

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

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Patient Safety Innovation May 31, 2023

Seeking a sustainable process to enhance their hospitals’ response to sepsis, a multidisciplinary team at WellSpan Health oversaw the development and implementation of a system that uses customized electronic health record (EHR) alert settings and a team of remote nurses to help frontline staff identify and respond to patients showing signs of sepsis. When the remote nurses, or Central Alerts Team (CAT), receive an alert, they assess the patient’s information and collaborate with the clinical care team to recommend a response.

Strategies to Improve Organizational Health Literacy.

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Patient Safety Primer May 31, 2023

Anyone can find it challenging to understand medical terms, and millions of Americans have trouble understanding and acting upon health information. Health literate organizations make health systems easier to navigate and health information easier to understand, improving healthcare delivery and outcomes.

The impact of nursing skill-mix on adverse events in intensive care: a single centre cohort study.

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Ross P, Hodgson CL, Ilic D, et al. Contemp Nurse. 2023;Epub May 8.

Improved nurse staffing ratios and nursing skill mix have been linked to improved safety outcomes. This retrospective cohort study of over 13,000 patients admitted to a tertiary intensive care unit (ICU) in Australia between 2016 and 2020 found that a great concentration of critical care registered nurses (CCRNs) was associated with a lower risk of adverse events.

Hospitals in two states denied an abortion to a miscarrying patient. Investigators say they broke federal law.

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Surana K. Pro Publica. May 19, 2023.

The unintended clinical consequences of abortion restrictions are beginning to emerge. This article shares how one woman faced personal health risks due to clinician concerns stemming from barriers to abortion care and how the Emergency Medical Treatment & Labor Act (EMTALA) may be employed to minimize care limitations in emergent pregnancy-related situations.

Why do so many Black women die in pregnancy? One reason: doctors don't take them seriously.

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Stafford K. AP News. May 23, 2023.

Racial inequities and implicit bias undermine safe maternal care. This article highlights the potential for maternal sepsis in the Black patient population and the role structural racism plays in this situation. The article is a part of the 2023 “Birth to Death" article series.

VHA's movement for change: implementing high-reliability principles and practices.

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Cox GR, Starr LM. J Healthc Manag. 2023;68:151-157.

Becoming a high-reliability organization (HRO) to improve patient safety is a goal of the Veterans Heath Administration (VHA). This commentary describes the VHA's implementation strategy and progress since 2019 at the patient, employee, and organizational levels. The three pillars of the VHA's HRO strategy are leadership commitment, a culture of safety, and continuous process improvement. Challenges associated with the COVID-19 pandemic are also discussed.

Reducing errors resulting from commonly missed chest radiography findings.

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Gefter WB, Hatabu H. Chest. 2023;163:634-649.

Cognitive bias, fatigue, and shift work can increase diagnostic errors in radiology. This commentary recommends strategies to reduce these errors in diagnostic chest radiography, including checklists and improved technology (e.g., software, artificial intelligence). In addition, the authors offer practical step-by-step recommendations and a sample checklist to assist radiologists in avoiding diagnostic errors.

Smart infusion pump investigations after an unexplained over-infusion.

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ISMP Patient Safety Alert! Acute care edition. May 18, 2023;28(10);1-3.

Dose error-reduction systems (DERS) and drug libraries are tools for use with smart infusion pumps to ensure safe intravenous medication administration. This article discusses infusion problems unrelated to user error that went undetected by the technology and reached patients. Recommendations to minimize similar occurrences include removing the involved device from service and investigating the incident.

Use of technology to improve the adherence to surgical safety checklists in the operating room.

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Pati AB, Mishra TS, Chappity P, et al. Jt Comm J Qual Patient Saf. 2023;Epub Apr 22.

The World Health Organization (WHO) Surgical Safety Checklist is widely used, but implementation challenges remain. This article describes the development of an electronic version of the surgical safety checklist adapted for use on a personal device, and compared its use against the traditional paper-based checklist. The electronic checklist had 100% use (compared to 98% for the traditional checklist) and significantly higher frequency of completion (100% vs. 27%).

Psychosocial processes in healthcare workers: how individuals' perceptions of interpersonal communication is related to patient safety threats and higher-quality care.

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Dietl JE, Derksen C, Keller FM, et al. Int J Environ Res Public Health. 2023;20:5698.

Miscommunication between healthcare providers can contribute to adverse events, but communication may be improved by strengthening psychological safety. This paper describes two studies on the association of communication, patient safety threats, and higher quality care and the mediating effect of psychological safety in obstetrical care. Results suggest psychological safety mediates the association of communication with quality of care and patient safety.

Clinical Investigation Booking Systems Failures: Written Communications in Community Languages.

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Farnborough, UK: Healthcare Safety Investigation Branch; April 2023.

Gaps in patient information processes can result in missed care opportunities that contribute to harm. This report examines language discordance in National Health Service written scheduling communications and its contribution to patients being lost to follow up. The primary improvement recommendation is to enhance the ability of providers to recognize primary languages of patients and provide written instructions accordingly.

Danger in discharge summaries: abbreviations create confusion for both author and recipient.

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Coghlan A, Turner S, Coverdale S. Intern Med J. 2023;53:550-558.

Use of abbreviations in electronic health records increases risk of misunderstandings, particularly between providers of different specialties. In this study, junior doctors and general practitioners were asked about their understanding of common, uncommon, and rare abbreviations used in hospital discharge notes. No abbreviation was interpreted in the same way by all respondents, and nearly all respondents left at least one abbreviation blank or responded that they didn't know.

Three missed critical nursing care processes on labor and delivery units during the COVID-19 pandemic.

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Edmonds JK, George EK, Iobst SE, et al. J Obstet Gynecol Neonatal Nurs. 2023;Epub May 10.

Staffing and nursing time at the bedside play a role in missed nursing care. This study focused on the role of COVID-19 on staffing and nursing time at the bedside and, therefore, on missed nursing care in labor and delivery units. During a peak of the pandemic, this study of obstetrics nurses found perceptions of nursing time at the bedside and adequate staffing played a significant role in missed nursing care.

SOPS Ambulatory Surgery Center Survey: What You Need to Know.

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Agency for Healthcare Policy and Research: April 27, 2023.

Ambulatory surgery centers (ASC) experience a variety of error types that can be acerbated by poor safety culture. This webcast provided information on AHRQ’s Surveys on Patient Safety Culture™ (SOPS®) Ambulatory Surgery Center (ASC) Survey, including a review of the SOPS ASC program, survey administration, database submission, and available resources.

TeamSTEPPS Master Trainer Course.

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AHA Training. MetroHealth, Cleveland, OH, June 21-22, 2023.

This education program will present group-focused opportunities for participants to learn how to apply Agency for Healthcare Quality and Research TeamSTEPPS 2.0 curriculum methods to develop staff training and improve team communication in their organizations.

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