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 158 Results

When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)!

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WebM&M Case November 30, 2023

A 67-year-old man with well-controlled type 2 diabetes mellitus underwent elective cardiac resynchronization and defibrillator device (CRT-D) implantation. The procedure was successful and he was discharged the next day with instructions to resume his prior medications, including empagliflozin. He presented to the emergency department the following day where he was diagnosed with euglycemic diabetic ketoacidosis (eDKA) and he was transferred to the intensive care unit (ICU) for insulin infusion.

Technology, Education and Safety

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Arnal-Velasco, D, ed. Curr Opin Anaesthesiol. 2023;36(6):649-705.

Adoption of new ideas is necessary to create safety in the perioperative environment. This collection of reviews illustrates relationships and tensions between technology, human factors and safety management that create the sociotechnical system within which technology is used to deliver anesthesia. Topics covered include artificial intelligence, decision making and perioperative deterioration.

Identifying contributing factors associated with dental adverse events through a pragmatic electronic health record-based root cause analysis.

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Kalenderian E, Bangar S, Yansane A, et al. J Patient Saf. 2023;19:305-312.

Understanding factors that contribute to adverse events (AE) is key to preventing them from recurring. This study used an electronic trigger tool to identify potential AE in two dental practices. Of 439 charts reviewed, 13% contained at least one AE. The most common AE was post-procedural pain; the expert panel reported 21% of those AEs were preventable. Person-related factors (e.g., supervision, fatigue) were the most common contributing factors.

Delay in Malignancy Diagnosis Reflects Systemic Failures.

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WebM&M Case October 31, 2023

A 32-year-old man presented to the hospital with a comminuted midshaft femoral fracture after a bicycle accident. Imaging suggested the fracture was pathologic and an open biopsy specimen was submitted to pathology for intraoperative consultation.

Look-alike medications in the perioperative setting: scoping review of medication incidents and risk reduction interventions.

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Ryan AN, Robertson KL, Glass BD. Int J Clin Pharm. 2023;Epub Sep 9.

Look-alike medications can cause confusion and contribute to medication administration errors. This scoping review including 18 articles identified several risk reduction strategies to mitigate look-alike medication errors in perioperative settings, such as improved labelling and standardization of storage. The authors note that further research is needed to assess the effectiveness of technology-based solutions, such as automated dispensing cabinets.

How does robotic-assisted surgery change OR safety culture?

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AMA J Ethics. 2023;25:E615-E623.

The safety culture of an operating room is known to affect teamwork and patient outcome. This article discusses the unique characteristics of robotic-assisted surgical practice and approaches teams and organizations can take to enhance communication that supports a safe care culture.

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.

Comparing rates of adverse events detected in incident reporting and the Global Trigger Tool: a systematic review.

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Hibbert PD, Molloy CJ, Schultz TJ, et al. Int J Qual Health Care. 2023;35:mzad056.

Accurate and reliable detection and measurement of adverse events remains challenging. This systematic review examined the difference in adverse events detected using the Global Trigger Tool compared to those detected via incident reporting systems. In 12 of the 14 included studies, less than 10% of adverse events detected using the Global Trigger Tool were also found in corresponding incident reporting systems. The authors of the review emphasize the importance of using multiple approaches and sources of patient safety data to enhance adverse event detection.

Perioperative Handoffs.

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Abraham J, Rosen M, Greilich PE eds. Jt Comm J Qual Patient Saf. 2023;49(8):341-434.

Handoffs occur several times during a surgical procedure, increasing the risk of communication mistakes and misunderstandings. This special issue explores perioperative handoffs and strategies to improve them. Topics covered include information accuracy, teamwork science, and artificial intelligence.

Association between electronic health record implementations and hospital-acquired conditions in pediatric hospitals.

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Rabbani N, Pageler NM, Hoffman JM, et al. Appl Clin Inform. 2023;14:521-527.

Implementation of or upgrades to new electronic health records (EHR) is a complex process which sometimes results in unforeseen negative consequences. This study examines hospital-acquired conditions (HACs) and care bundle compliance rates at 27 pediatric hospitals before, during, and after implementation or upgrade of EHR systems. Contrary to previous studies, no significant differences were found in either HAC or bundle compliance rates.

Patient safety of perioperative medication through the lens of digital health and artificial intelligence.

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Ye J. JMIR Periop Med. 2023;6:e34453.

Perioperative medication errors are common. This article highlights several interventions to reduce the risk of perioperative medication errors, including improved medication labeling, adoption of artificial intelligence for decision support and risk prediction, and the use of health information technology (IT), such as computerized physician order entry (CPOE), electronic medication administration records (eMAR), and barcode medication administration (BCMA).

Evaluation of detected medication errors within the operating room at an academic medical center.

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Wolf M, Rolf J, Nelson D, et al. Hosp Pharm. 2023;58:309-314.

Medication administration is a complex process and is a common source of preventable patient harm. This retrospective chart review of 145 surgical patients over a two-month period found that 98.6% of cases involved a potential medication error, most frequently due to potential dose omissions and involving vasopressors, opioids, or neuromuscular blockers.

Perioperative handoff enhancement opportunities through technology and artificial intelligence: a narrative review.

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Sparling J, Hong Mershon B, Abraham J. Jt Comm J Qual Patient Saf. 2023;49:410-421.

Multiple handoffs can occur during perioperative care, which can increase the risk for errors and patient harm. This narrative review summarizes research on the benefits, limitations, and implementation challenges of electronic tools for perioperative handoffs and the role of artificial intelligence (AI) and machine learning (ML) in perioperative care.

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;49:572-577.

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%).

Factors contributing to preventing operating room "never events": a machine learning analysis.

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Arad D, Rosenfeld A, Magnezi R. Patient Saf Surg. 2023;17:6.

Surgical never events are rare but devastating for patients. Using machine learning, this study identified 24 contributing factors to two types of surgical never events - wrong site surgery and retained items. Communication, the number and type of staff present, and the type and length of surgery were identified contributing factors.

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.

APSF Stoelting Conference.

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Anesthesia Patient Safety Foundation. September 6–7, 2023.

Anesthesia is a high-risk activity that has achieved safety successes. This hybrid conference explored topics related to the theme of “Emerging Medical Technologies – A Patient Safety Perspective on Wearables, Big Data and Remote Care.” Videos of the sessions are available.

Potential uses of AI for perioperative nursing handoffs: a qualitative study.

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King CR, Shambe A, Abraham J. JAMIA Open. 2023;6:ooaf015.

Handoffs and transitions of care represent a vulnerable time for patients as important information must be shared and understood by multiple people. This study focuses on postoperative nurse handoffs, specifically regarding situational awareness and anticipatory guidance, and the role artificial intelligence (AI) could play in improving handoffs. Five themes were uncovered, including the importance of situational awareness and associated barriers, how AI could address those barriers, and how AI could result in new/additional barriers.

Why hospitals still make serious medical errors—and how they are trying to reduce them.

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Landro L. Wall Street Journal. March 12, 2023.

Patient harm from health care is persistent despite decades of effort to address problems that degrade care. This article discusses the potential that improved technology use has in reducing medication errors, falls, surgical errors, and high-risk hospital-acquired infections.

Hospital ‘black boxes’ put surgical practices under the microscope.

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Sadick B. Wall Street Journal. March 19, 2023.

Safety information systems that track action in real time can reveal a trove of data about how teams and procedures progress. This news article describes the use of a black-box system in the operating room. Its use by hospitals in the United States is described to illustrate the value of black box data to inform learning and improvement strategies.

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