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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 44 Results
Melnyk BM, Hsieh AP, Tan A, et al. J Occup Environ Med. 2023;65:699-705.
Many healthcare professionals experienced adverse emotional and psychological outcomes during the COVID-19 pandemic. This survey of 665 health system pharmacists found that pharmacists working in settings with higher levels of workplace wellness support were less likely to experience depression, anxiety, or burnout, and report higher levels of professional quality of life during the COVID-19 pandemic.
Fink DA, Kilday D, Cao Z, et al. JAMA Netw Open. 2023;6:e2317641.
Ensuring all pregnant individuals receive safe maternal care is a national health priority. Using a large national database, this study describes trends in delivery-related severe maternal morbidity (SMM) and mortality in the United States. Maternal mortality decreased for all racial, ethnic, and age groups, while SMM increased for all groups, particularly racial and ethnic minoritized groups. Patients with COVID-19 had a significantly increased risk of death. PSNet features a curated library of maternal safety resources.
Murray JS, Lee J, Larson S, et al. BMJ Open Qual. 2023;12:e002237.
A “just culture” balances organizational responsibility and individual accountability after an error occurs. This integrative review of 16 articles identified four concepts critical to implementing a “just culture” in healthcare settings – leadership commitment, education and training, accountability, and open communication.
Hessels AJ, Guo J, Johnson CT, et al. Am J Infect Control. 2023;51:482-489.
Standard precautions, including hand hygiene and sharps safety, keep patients and staff safe, but adherence is suboptimal. An earlier systematic review shows an association between standard precaution compliance and overall safety climate. This study aimed to determine if adherence to standard precautions and safety climate were associated with healthcare associated infection (HAI) rates. Adherence rates were low (64%) and associated with HAI and healthcare worker needlesticks.
Grauer A, Kneifati-Hayek J, Reuland B, et al. J Am Med Inform Assoc. 2022;29:909-917.
J Am Med Inform Assoc … Problem lists , while an important … health records (EHR) (medication ordered lacking a corresponding problem on the problem list) in two different … hospitals using different EHRs. Both sites resulted in a proportion of new problems being added to the problem list …
Fink BC, Uyttebrouck O, Larson RS. J Law Med Ethics. 2020;48:249-258.
The overprescribing of opiates is a known contributor to the opioid epidemic. This essay describes governmental action taken to adjust prescribing patterns, their effect, and strategies to increase the impact of these actions on opioid misuse and patient harm.
Hessels AJ, Paliwal M, Weaver SH, et al. J Nurs Care Qual. 2019;34:287-294.
J Nurs Care Qual … J Nurs Care Qual … This cross-sectional study examined … to reduce missed nursing care and improve safety. … Hessels AJ, Paliwal M, Weaver SH, Siddiqui D, Wurmser TA. … on Missed Nursing Care and Adverse Patient Events.  J Nurs Care Qual . 2019;34(4):287–294. …
Larson LA, Finley JL, Gross TL, et al. Jt Comm J Qual Patient Saf. 2019;45:74-80.
Workplace violence in the health care setting is common and poses an ongoing risk for providers and staff. The Joint Commission issued a sentinel event alert to raise awareness about the risks associated with physical and verbal violence against health care workers and suggests numerous strategies organizations can use to address the problem, including establishing reporting systems and developing quality improvement interventions. The authors describe a quality improvement initiative involving the development and iterative testing of a huddle handoff tool to optimize communication between the emergency department (ED) and an admitting unit regarding patients with the potential for violent behavior. The huddle tool led to improved perceptions of safety during the patient transfer process by both the ED nurses and the admitting medical units. An accompanying editorial highlights the importance of taking a systems approach to address workplace safety. A PSNet perspective explored how a medical center developed a process to identify, prioritize, and mitigate hazards in health care settings.

Azar FM, ed. Orthop Clin North Am. 2018;49(4):A1-A8,389-552.

Quality and value have intersecting influence on the safety of health care. Articles in this special issue explore key principles of safe orthopedic care for both adult and pediatric patients. Topics covered include leadership's role in implementing sustainable improvement, postsurgery patient education as a safety tactic, and the impact of surgical volume on safe, high-quality care.
Cohen CC, Liu J, Cohen B, et al. Infect Control Hosp Epidemiol. 2018;39:509-515.
This matched case-control study examined costs and payments to hospitals related to hospital-acquired central line infections and catheter-associated urinary tract infections. Investigators found that hospitals could either experience financial penalty or gain depending on the particular payment structure for the patient. They suggest aligning payment structures more closely with safety goals.

AJR Am J Roentgenol. 2017;209(5):965-1008;w333-w334.

… Radiologists play a critical role in safe diagnostic imaging and communication … delay , uncertainty , and miscommunication. … AJR Am J Roentgenol. 2017;209(5):965-1008;w333-w334. … Duszak R Jr … … … JM … A … DB … CP … B … S … G … RC … EA … CC … CI … JM … E … AB … R … MA … HH … J … Berlin … Balthazar … …
Larson DB, Donnelly LF, Podberesky DJ, et al. Radiology. 2017;283:231-241.
Improving the culture of safety within health care is an essential component of preventing errors. This commentary discusses the culture of radiology in the context of recent progress in understanding and reducing diagnostic error. The authors suggest that peer-oriented feedback and assessment would drive progress in improving safety in radiology.
Glickman SW, Mehrotra A, Shea CM, et al. J Patient Saf. 2020;16:211-215.
J Patient Saf … Patients' perceptions of care may provide … patients seen in an academic emergency department over a one-year period. They found that patients were able to … accurately identify adverse events and near misses, only a small fraction of which were also submitted to an existing …
Freedberg DE, Salmasian H, Cohen B, et al. JAMA Intern Med. 2016;176:1801-1808.
… … JAMA Intern Med … Clostridium difficile diarrhea is a common and highly morbid health care–associated infection . This study demonstrated that when a hospitalized patient receives antibiotics, the next patient …

Kruskal JB, Kung JW, eds. Radiographics. 2015;35(6):1627-1848.

Increased radiation exposure has emerged as a patient safety problem, with the potential to result in harm for providers and patients. Articles in this special issue explore noninterpretive skills in radiologic practice, such as root cause analysis, professionalism, and error identification and reduction.
Larson CK, Kao H. JAMA Intern Med. 2015;175:1750-1751.
… patients. This commentary describes an incident involving a patient with moderate dementia that worsened when opioids were prescribed following a fall. After a geriatrician evaluated the patient and suspected …