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Promoting Patient Safety.

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AHRQ’s Patient Safety Network (PSNet) features a collection of the latest news and resources on patient safety, innovations and toolkits, opportunities for free CME and trainings. The platform provides powerful searching and browsing capability, as well as the ability for users to customize the site around their interests (My Profile).

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Medication Errors/Preventable Adverse Drug Events
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July 10, 2024 Weekly Issue

PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety.

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Study
Identifying and measuring administrative harms experienced by hospitalists and administrative leaders.
Burden M, Astik GJ, Auerbach AD, et al. JAMA Intern Med. 2024;Epub Jun 24.
Administrative harm (AH) may emerge from organizational decisions based on financial, regulatory, and other non-critical factors and can adversely impact patients and staff. In this study, hospitalists, leaders, researchers, and patient and family advocates were largely unaware of the term administrative harm but were familiar with these types of decisions. Three themes emerged: AH is pervasive and comes...
Study
Evaluating the prevalence of four recommended practices for suicide prevention following hospital discharge.
Chitavi SO, Patrianakos J, Williams SC, et al. Jt Comm J Qual Patient Saf. 2024;50:393-403.
Preventing suicide among patients who express suicidal ideation or are identified at risk of suicide during care is a Joint Commission National Patient Safety Goal. This study surveyed Joint Commission-accredited hospitals regarding their implementation of four recommended discharge practices for suicide prevention: formal safety planning, lethal-means safety planning, warm handoffs to outpatient care,...
Study
Advanced practice nurses' experiences of patient safety: a focus group study.
Glarcher M, Rihari-Thomas J, Duffield C, et al. Contemp Nurse. 2024;Epub Jun 11.
Each member of the care team brings a unique perspective towards patient safety. In this study, advanced practice nurses (APN) working in hospitals or community care described their experiences of patient safety improvement. Six themes were identified, including seeing patient safety as their top priority and being a role model to other staff.
Study
Building a resilient patient safety culture: a large healthcare organization's approach to systematically reviewing serious harm events.
Harvey B, Dhalla IA, O'Neill C, et al. Healthc Q. 2024;27:19-25.
Error reporting and analysis is a key element of a learning organization. This article describes one healthcare organization's approach to systematic review of serious harm events through use of a standardized classification system, frequent meetings, inclusion of the patient and family voice, and application of human factors strategies.
Study
Optimizing the use of dose error reduction software on intravenous infusion pumps.
Hughes K, Cole M, Tims D, et al. Hosp Pediatr. 2024;14:448-454.
Smart pumps with dose error reduction software (DERS) can reduce adverse drug events, but alert fatigue can result in staff resistance and unsafe workarounds. In this study, a pediatric hospital aimed to increase use of smart pumps with DERS from 46% compliance at baseline to 75%. Updating the drug library resulted in the largest increase in compliance and decrease in alerts.
Study
Infection control measure performance in long-term care hospitals and their relationship to Joint Commission accreditation.
Schmaltz SP, Longo BA, Williams SC. Jt Comm J Qual Patient Saf. 2024;50:425-434.
Organizations such as the Joint Commission provide resources and guidance to help hospitals reduce healthcare associated infections (HAIs). Using CMS data from 2017 to 2021, this analysis compared the incidence of HAIs in Joint Commission-accredited versus non-accredited long-term care hospitals (LTCHs). The researchers found that accredited LTCHs had lower rates of central line-associated blood stream...

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Training and Education

Update Date: July 10, 2024

WebM&M Case Studies & Spotlight Cases

WebM&M (Morbidity & Mortality Rounds on the Web) features expert analysis of medical errors reported anonymously by our readers. Spotlight Cases include interactive learning modules available for CME. Commentaries are written by patient safety experts and published monthly. Contribute by Submitting a Case anonymously.

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Upcoming Events

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International Meeting/Conference
HSJ Patient Safety Congress.

Health Service Journal. September 16-17, 2024. Manchester Central Convention Complex, Manchester UK.

Improvement Resources
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Innovations

The Patient Safety Innovations Exchange highlights important innovations that can lead to improvements in patient safety.

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Toolkits

Toolkits provide practical applications of PSNet research and concepts for front line providers to use in their day to day work.

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