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 69 Results

Just what the doctor ordered: missed ordering of venous thromboembolism chemoprophylaxis is associated with increased VTE events in high-risk general surgery patients.

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Baimas-George MR, Ross SW, Yang H, et al. Ann Surg. 2023;278:e614-e619.

Hospital-acquired venous thromboembolism (VTE) remains a significant source of preventable patient harm. This study of 4,252 high-risk general surgery patients found that only one-third received care in compliance with VTE prophylaxis guidelines. Patients receiving guideline-compliant care experienced shorter lengths of stay (LOS), fewer blood transfusions, and decreased odds of having a VTE, emphasizing the importance of initiating VTE chemoprophylaxis in high-risk general surgery patients.

Unstoppable: this doctor has been investigated at every level of government. How is he still practicing?

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Waldman A. ProPublica. August 9, 2023

Systemic failures can enable poor practice to perpetuate without regard to safety. This news feature reports on systemic flaws that enabled a vascular surgeon with questionable business and clinical skills to continue to practice after numerous regulatory organizations investigated his clinics, and after patients reported harm.

Unpacking the complexity of COVID-19 fatalities: adverse events as contributing factors--a single-center, retrospective analysis of the first two years of the pandemic.

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Zińczuk A, Rorat M, Simon K, et al. Viruses. 2023;15:1430.

The COVID-19 pandemic exacerbated many existing patient safety challenges. This retrospective analysis of 477 fatal COVID-19 cases at one hospital in Poland found that one-third of patients experienced a healthcare-acquired infection during their hospitalization as well as other hospital-acquired complications, including thrombolytic and/or bleeding complications, acute kidney injury, and exacerbation of chronic heart disease. The analysis also found that many patients experienced delays in specialist treatment (33%) or lack of specialist treatment (17%) during their hospitalization.

Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery.

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WebM&M Case June 28, 2023

A 25-year-old obese patient required an emergency cesarean delivery. As the obstetric team was in a hurry to deliver the baby, the team huddle was rushed. After the delivery, the anesthesia care provider discovered that the patient had received subcutaneous enoxaparin 40 mg four hours preoperatively, which was not mentioned by the obstetric team during the previous huddle.

Racial, Ethnic, and Payer Disparities in Adverse Safety Events: Are there Differences across Leapfrog Hospital Safety Grades?

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Gangopadhyaya A, Pugazhendhi A, Austin M et al. Washington DC: Leapfrog Group; 2023.

Adverse events in patients of color continue to be connected with systematic racism and biases. This report summarizes the distribution of patient safety events among Black and Hispanic patients across 2,019 Leapfrog patient safety graded hospitals and found that they experience adverse surgical events at a higher level than white patients.

Inappropriate prescriptions of direct oral anticoagulants (DOACs) in hospitalized patients: a narrative review.

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van der Horst SFB, van Rein N, van Mens TE, et al. Thromb Res. 2023;Epub Mar 27.

Although direct-acting oral anti-coagulants (DOACs) are considered safer than warfarin, DOAC dosing is complex and can lead to medication errors. This narrative review discusses the clinical consequences of potentially inappropriate inpatient prescribing of DOACs and how pharmacists and anticoagulant stewardship programs can optimize inpatient DOAC treatment.

Curated Libraries

Implementation of Patient Safety Projects Curated Library

May 4, 2023

The implementation of effective patient safety initiatives is challenging due to the complexity of the health care environment. This curated library shares resources summarizing overarching ideas and strategies that can aid in successful program execution, establishment, and sustainability.

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.

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.

Modes of failure in venous thromboembolism prophylaxis.

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Richie CD, Castle JT, Davis GA, et al. Angiology. 2022;73:712-715.

Hospital-acquired venous thromboembolism (VTE) continues to be a significant source of preventable patient harm. This study retrospectively examined patients admitted with VTE and found that only 15% received correct risk stratification and appropriate management and treatment. The case review found that patients were commonly incorrectly stratified, received incorrect pharmaceutical treatment, or inadequate application of mechanical prophylaxis (e.g., intermittent compression).

Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan.

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WebM&M Case September 28, 2022

This case describes a 20-year-old woman was diagnosed with a pulmonary embolism and occlusive thrombus in the right brachial vein surrounding a peripherally inserted central catheter (PICC) line (type, gauge, and length of time the PICC had been in place were not noted). The patient was discharged home but was not given any supplies for cleaning the PICC line, education regarding the signs of PICC line infection, or referral to home health services.

Healthcare-associated adverse events in alternate level of care patients awaiting long-term care in hospital.

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Lim Fat GJ, Gopaul A, Pananos AD, et al. Geriatrics (Basel). 2022;7:81.

The risk of adverse events increases with prolonged hospital stays. This descriptive study examined adverse events among older patients with extended hospital admissions pending transfer to long-term care (LTC) settings at two Canadian hospitals. Analyses showed that patients were designated as “alternate level of care” (ALC) for an average of 56 days before transfer to LTC and adverse events such as falls and urinary tract infections were common.

The association of acute COVID-19 infection with Patient Safety Indicator-12 events in a multisite healthcare system.

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Bhakta S, Pollock BD, Erben YM, et al. J Hosp Med. 2022;17:350-357.

The AHRQ Patient Safety Indicators (PSI) capture the quality and safety in inpatient care and identify potential complications. This study compares the incidence of PSI-12 (perioperative venous thromboembolism (VTE)) in patients with and without acute COVID-19 infection. Patients with acute COVID-19 infection were at increased risk for meeting the criteria for PSI-12, despite receiving appropriate care. The researchers suggest taking this into consideration and updating PSIs, as appropriate.

The Johns Hopkins Venous Thromboembolism (VTE) Collaborative Studies and Implements Methods to Prevent Avoidable Cases of Hospital Associated VTE

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Patient Safety Innovation April 7, 2022

Venous thromboembolism (VTE) is a serious but preventable medical condition in which blood clots form in the veins.

Prescribing errors with low-molecular-weight heparins.

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Slikkerveer M, van de Plas A, Driessen JHM, et al. J Patient Saf. 2021;17:e587-e592.

Anticoagulants, such as low-molecular-weight heparin (LMWH), are known to be high-risk for adverse drug events. This cross-sectional study identified prescribing errors – primarily lack of dosage adjustment for body weight and/or renal function – among one-third of LMWH users admitted to one hospital over a five-month period.

Improving peripherally inserted central catheter appropriateness and reducing device-related complications: a quasiexperimental study in 52 Michigan hospitals.

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Chopra V, O'Malley M, Horowitz J, et al. BMJ Qual Saf. 2022;31:23-30.

Peripherally inserted central catheters (PICC) represent a key source of preventable harm. Using the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC), the authors sought to determine if the appropriateness of PICC use decreased related medical complications including catheter occlusion, venous thromboembolism, and central line-associated bloodstream infections. Use of MAGIC in 52 Michigan hospitals increased appropriate use of PICC lines and decreased medical complications. In a 2019 PSNet Perspective, Dr. Vineet Chopra described the development and implementation of MAGIC in Michigan hospitals.

Investigation into Management of Venous Thromboembolism Risk in Patients Following Thrombolysis for an Acute Stroke.

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Farnborough, UK; Healthcare Safety Investigation Branch. October 2020

Errors of omission in routine care can result in patient harm. This report discusses factors contributing to a pulmonary embolism in a recovering stroke patient acerbated by a lack of intended but omitted venous thromboembolism or VTE preventative care. The system improvement recommendations drawn from the incident analysis include that the UK National Health Service develop a standardized approach to VTE risk assessment and broad-based training to enable a cross-section of clinicians to use VTE prevention devices as required.

A comprehensive estimation of the costs of 30-day postoperative complications using actual costs from multiple, diverse hospitals.

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Merkow RP, Shan Y, Gupta AR, et al. Jt Comm J Qual Patient Saf. 2020;46:558-564.

Postoperative complications can increase costs due to additional healthcare utilization such as further testing, reoperation, or additional clinical services. This study used data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) to estimate 30-day costs resulting from postoperative complications. Prolonged ventilation, unplanned intubation, and renal failure were associated with the highest cost per event, whereas urinary tract infection, superficial surgical site infection, and venous thromboembolism were associated with the lowest cost per event.

Making Healthcare Safer III Report

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Perspective on Safety March 30, 2020

This perspective discusses the Making Healthcare Safer Report, what is new in the recently released third edition, and how the report can be used.

In Conversation With... Ann Gaffey, RN, MSN, CPHRM and Bruce Spurlock, MD

Ann D. Gaffey, RN, MSN, CPHRM, DFASHRM is the President of Healthcare Risk and Safety Strategies, LLC. Bruce Spurlock, MD is the President and CEO of Cynosure Health. We spoke with them about their role in the development of the Making Healthcare Safer III Report and what new information they think audiences will find particularly useful and interesting.

Updates in the Management of High-Risk Pulmonary Embolism

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WebM&M Case May 1, 2019

Following catheter-guided thrombolysis for a large saddle pulmonary embolism, a man was monitored in the intensive care unit. The catheters were removed the next day, and the patient was sent from the interventional radiology suite to the postanesthesia care unit, after which he was transferred to a telemetry bed on the stepdown unit. No explicit plan for anticoagulation was discussed with the accepting medical team. Shortly after the nurse found the patient lethargic, tachycardic, and hypoxic, the patient lost his pulse and a code was called.

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