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Patient Safety Network

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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The PSNet Collection

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November 20, 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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Review
Experiences with diagnostic delay among underserved racial and ethnic patients: a systematic review of the qualitative literature.
Faugno E, Galbraith AA, Walsh KE, et al. BMJ Qual Saf. 2024;Epub Nov 4.
Historically, underserved racial and ethnic populations have been disproportionately affected by delayed diagnosis. In this review of quantitative studies conducted in the US, patients and caregivers in underserved communities reported several factors contributing to delayed diagnosis. Socioeconomic and sociocultural factors included healthcare avoidance, stigma, and distrust in the healthcare system....
Review
Nurse burnout and patient safety, satisfaction, and quality of care: a systematic review and meta-analysis.
Li LZ, Yang P, Singer SJ, et al. JAMA Netw Open. 2024;7:e2443059.
Nurse burnout increased during the pandemic and remains prevalent. This review sought to determine the association between nurse burnout and patient safety, patient satisfaction, and quality of care. Nurse burnout increased over time and was negatively associated with these factors. The association between the subcomponents of burnout (e.g., safety culture, emotional exhaustion, and depersonalization)...
Study
Implementation of a standardized tool for root cause analysis selection.
Wahlstedt E, Levy BE, Scott E, et al. J Patient Saf. 2024;Epub Oct 18.
The root cause analysis or RCA2 framework is a standardized approach to identify patient safety incidents based on their potential harm and frequency. In this study, researchers used an RCA2 algorithm to identify high-risk events for root cause analysis. Among 104 cases identified from the VA health system, the algorithm recommended nearly 57% for RCA. In comparison, only 17% of cases met the current...
Study
Family medicine presence on labor and delivery: effect on safety culture and cesarean delivery.
VanGompel EW, Singh L, Carlock F, et al. Ann Fam Med. 2024;22:375-382.
Rural care settings face unique challenges in the provision of safe obstetric care. This study explored whether the presence of family medicine (FM) physicians (who are more likely to attend births in rural settings without access to obstetricians or midwives) impacts safety culture and perinatal outcomes. Researchers surveyed 849 clinicians from 39 hospitals in Iowa and found that FM-only hospitals had...

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Training and Education

Update Date: October 30, 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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A Tale of Two Falls
Victoria Jackson, DNP, RN, PHN, FNP-C, PA-C and Anna Satake, PhD, MSN, GCNS, RN | October 30, 2024

These cases involve two elderly patients presenting to the emergency department (ED) who suffered falls during their care, despite recognition of risk factors including previous... Read More

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United States Meeting/Conference
2024 IHI Forum

Institute for Healthcare Improvement. Orlando World Center Marriott, Orlando, FL, December 9-11, 2024.

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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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