What’s New in the Patient Safety World


August 2008

AHRQ’s New Patient Safety Primers



AHRQ PSNet has introduced a series of patient safety primers. The following topics are covered:


They are, in fact, primers – meaning they are very introductory works on several important areas related to patient safety. However, each has extensive links to both classic and contemporary bibliographic references and tools.


The primer on Computerized Physician Order Entry (CPOE) discusses the basic concepts of  both CPOE and clinical decision support systems (CDSS) and provides data about the efficacy of CPOE and CDSS and the unintended consequences. Then it provides references (with links) to over 180 resources on CPOE/CDSS including journal articles, newspaper/magazine articles, books, and audiovisual tools.


The primer on Handoffs & Signouts provides background on the problematic issues with communication in healthcare and discusses structured signout techniques like SBAR and ANTICipate. Medication reconciliation is included as one of the critical areas prone to communication difficulties. The reference list of over 400 resources includes links to some of the classic literature on handoffs in other high-risk industries and includes topics like medication reconciliation, correct patient identification, followup of diagnostic testing results, and many more.


Medication Reconciliation also gets its own primer. Though the text of this primer is extremely brief, there are excellent links to toolkits and papers on technological solutions to this issue which continues to perplex us all.


Health Care-Associated Infections (HAI’s) focuses on the four most common nosocomial infections: Central venous catheter–related bloodstream infections (CRBSI), Surgical site infection (SSI), Ventilator-associated pneumonia (VAP), and Catheter-associated urinary tract infection (CAUTI). A simple table outlines the more common evidence-based interventions to help prevent these infections. There are good links to CDC guidelines on infection control and the great work by Peter Pronovost and Atul Gawande on use of checklists as a simple but powerful technique in infection prevention (not to mention the many other uses of checklists in patient safety).


Never Events is primarily a compilation of serious untoward patient consequences appearing in Joint Commission’s Sentinel Events, or the Minnesota Department of Health’s list of serious reportable events, and NQF’s list of “never events”. But again – good  references.


Patient Disclosure is a good discussion about the relatively recent trend in healthcare to both disclose and apologize to patients and/or their families and loved ones when an adverse event occurs as the result of the healthcare process itself. It discusses the studies supporting disclosure/apology, including continued controversies, and has good references about how such is best done. It notes the position statements of patient safety organizations and specialty societies plus the legislation in many states on this issue.


Rapid Response Systems remain controversial since evidence of their efficacy remains unclear at this time. However, the concept of earlier identification of clinical deterioration in patients is a logical patient safety concept. This primer talks about IHI’s role in bringing this issue to the table and Joint Commission’s endorsement of the need for earlier response, criteria for activating rapid response teams, and the various models for rapid response teams. The primer is nonjudgemental and notes the pros and cons of rapid response teams. Most importantly, the references point you to the evidence you need to help you decide what your organization will do to foster earlier (preventive) interventions.


Root Cause Analysis is only a few paragraphs long but its value is in its very extensive list of references, guidelines and tools for performing RCA’s.



If you are looking for one comprehensive “chapter” on any of these eight topics, you won’t find them here. However, if you want to easily get to a comprehensive bibliography and list of tools and other resources related to these topics, you can’t go wrong by visiting this site. AHRQ does a great job of putting the tools you need at your fingetrips.




Update: See our February 2009 What’s New in the Patient Safety World column “Some More New AHRQ Patient Safety Primers”.












Patient Safety Tip of the Week Archive


What’s New in the Patient Safety World Archive