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 1738 Results

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.

Patients admitted on weekends have higher in-hospital mortality than those admitted on weekdays: analysis of national inpatient sample.

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Manadan A, Arora S, Whittier M, et al. Am J Med Open. 2023;9:100028.

The ”weekend effect” refers to worse outcomes among patients admitted on the weekend versus weekday. Based on a sample of over 121 million adult hospital discharges from 2016 to 2019, researchers examined the association between several different variables and in-hospital death. Multivariable analyses identified several predictors of in-hospital death (e.g., older age, higher number of comorbidities, etc.) and the researchers found that patients admitted on weekends underwent fewer procedures and had higher mortality rates compared to patients admitted on weekdays. The authors suggest that improved staffing and availability of procedures may improve mortality.

Implementation of ED I-PASS as a standardized handoff tool in the pediatric emergency department.

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Yanni E, Calaman S, Wiener E, et al. J Healthc Qual. 2023;45:140-147.

I-PASS is a structured handoff tool that aims to improve communication and reduce adverse events during transitions of care. This article describes the implementation of a modified I-PASS tool for use in the emergency department (ED I-PASS) to improve transitions of care between pediatric emergency medicine physicians. Implementation of ED I-PASS decreased the perceived loss of key patient information during transitions of care (from 75% to 37.5%).

Identification of patient safety threats in a post-intensive care clinic.

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Karlic KJ, Valley TS, Cagino LM, et al. Am J Med Qual. 2023;38:117-121.

Because patients discharged from the intensive care unit (ICU) are at increased risk of readmission and post-ICU adverse events, some hospitals have opened post-ICU clinics. This article describes safety threats identified by post-ICU clinic staff. Medication errors and inadequate medical follow-up made up nearly half of identified safety threats. More than two-thirds were preventable or ameliorable.

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.

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.

Analysis of reported suicide safety events among veterans who received treatment through Department of Veterans Affairs-contracted community care.

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Riblet NB, Soncrant C, Mills PD, et al. Mil Med. 2023;Epub Mar 31.

Patient suicide is a sentinel event, and suicide among veterans has gained attention. In this retrospective analysis of suicide-related events reported to the Veterans Health Administration (VHA) National Center for Patient Safety between January 2018 and June 2022, researchers found that deficiencies in mental health treatment, communication challenges, and unsafe environments were the most common contributors to suicide-related events.

Death Inside Lemuel Shattuck Hospital: A Case Study on Medical Treatment for Persons with Mental Health Disabilities.

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Massachusetts Protection and Advocacy. Boston, MA: Disability Law Center; May 8, 2023.

Behavioral health patients present unique challenges in their care that can contribute to unintended harm. The analysis examines a delayed diagnosis, referral, and treatment of skin cancer that contributed to the death of a patient. Suggestions for improvement included conducting a root cause analysis to identify systemic problems, use of photography to track skin lesion progression, and implementation of a warm handoff process to improve staff communication.

Effects of a multimodal transitional care intervention in patients at high risk of readmission: the TARGET-READ randomized clinical trial.

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Donzé JD, John G, Genné D, et al. JAMA Internal Med. 2023;Epub May 1.

Adverse events and unplanned, preventable readmissions occur in approximately 20% of patients following discharge from the hospital. This randomized clinical trial compares standard care with a multi-modal discharge intervention targeting patients at highest risk of unplanned readmission. Despite the intensity of the intervention, there was no statistical difference between that intensity and the standard of care in unplanned readmission, time to readmission, or death.

Perceived discrimination in the community pharmacy: a cross-sectional, national survey of adults.

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Baffoe JO, Moczygemba LR, Brown CM. J Am Pharm Assoc (2003). 2023;63:518-528.

Minoritized and vulnerable people often experience delays in care due to systemic biases. This survey study examined the association between perceived discrimination at community pharmacies and foregoing or delaying picking up medications. Participants reported discrimination based on race, age, sexual orientation, ethnicity, income, and prescription insurance; those participants were more likely to delay picking up their medications. There was no association with discrimination and foregoing medications.

Nurse staffing and inpatient mortality in the English National Health Service: a retrospective longitudinal study.

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Zaranko B, Sanford NJ, Kelly E, et al. BMJ Qual Saf. 2023;32:254-263.

Poor nurse staffing has long been recognized as a patient safety issue. This analysis of three UK National Health Service hospitals examined the differences in in-hospital deaths among different nursing team sizes and compositions. Researchers identified higher inpatient mortality with higher nurse staffing and seniority levels (i.e., more registered nurses [RNs]) but no changes in mortality related to health care support workers (HCSW). Authors surmised that HCSWs may not be a substitute for RNs.

Delays in care during the COVID-19 pandemic in the Veterans Health Administration.

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Mills PD, Louis RP, Yackel E. J Healthc Qual. 2023;Epub Apr 11.

Changes in healthcare delivery due to the COVID-19 pandemic resulted in delays in care that can lead to patient harm. In this study using patient safety event data submitted to the VHA National Center of Patient Safety, researchers identified healthcare delays involving laboratory results, treatment and interventional procedures, and diagnosis.

Teamwork, clinical leadership skills and environmental factors that influence missed nursing care - a qualitative study on hospital wards.

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Beiboer C, Andela R, Hafsteinsdóttir TB, et al. Nurse Educ Pract. 2023;68:103603.

Myriad factors contribute to missed nursing care including staffing, team and group norms, and teamwork. Nurses in this study described four themes that contributed to missed nursing care: teamwork in nursing wards; informal teaching and communication; influence of formal and informal leaders; and influencing factors in nurses’ work environment. Developing nurses' clinical leadership skills may improve teamwork and reduce missed care.

Floating to intensive care units: nurses' messages for instant action to promote patient safety.

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Ahmed FR, Timmins F, Dias JM, et al. Nurs Crit Care. 2023;Epub Apr 1.

Staffing shortages are temporarily alleviated with floating or redeployed staff. This qualitative study of intensive care unit (ICU) critical care nurses and floating non-critical care nurses sought to identify the pros and cons of floating nurses, and strategies to improve patient safety. Floating nurses reported concerns surrounding unfamiliarity with the types of patients or locations of equipment. Critical care nurses reported cognitive overload with doing their routine duties plus orienting floating nurses. One recommendation to improve safety is competency-based nursing curriculum and provide floating nurses occasional training/experience in the ICU.

CUSP Implementation Training.

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Armstrong Institute for Patient Safety and Quality.

The comprehensive unit-based safety program (CUSP) approach emphasizes improving safety culture through a continuous process of reporting and learning from errors, improving teamwork, and engaging staff at all levels in safety efforts. Available on demand and live, this session covers how to utilize CUSP, including understanding and addressing challenges to implementation. The next virtual session will be held July 18, 2023.

Improving Diagnostic Safety and Quality

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Perspective on Safety April 26, 2023

Throughout 2022, AHRQ PSNet has shared research that elucidates the complex nature of misdiagnosis and diagnostic safety. This Year in Review explores recent work in diagnostic safety and ways that greater safety may be promoted using tools developed to improve diagnostic practices.

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