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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 183 Results

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 … … Ambardekar … Olson … ECHO … Abraham … Rosen … Conn … Wu … Anglade … Peifer … Lane-Fall … Koilor … Givan … Klaiman … O'Hagan … AJ … MM … ND … I … F … E … N … O … R … AT … N … A … K … E … L … M … A … D … Collaborative … J … M … J … J … E …
Conn Busch J, Wu J, Anglade E, et al. Jt Comm J Qual Patient Saf. 2023;49:365-372.
Structured handoffs are recognized as a method to ensure that complete, accurate information is shared between teams. This article describes the impact of the Handoffs and Transitions in Critical Care (HATRICC) study on accuracy and completeness of handoff before and after implementation of a structured handoff tool. Post-intervention, the accuracy and completeness of handoffs improved. Omissions, mortality, and length of intensive care unit (ICU) stay were reported in a 2019 study.
Chen H-W, Wu J-C, Kang Y-N, et al. Nurse Educ Today. 2023;126:105831.
Patient safety can be improved when all staff feel empowered to speak up about errors. In this systematic review, the authors identified 11 studies on the effectiveness of trainings to increase nurses' assertiveness to report medical errors. Interventions resulted in significant improvement in nurses' speaking up behavior, but not their attitude or confidence after training. Structured content, use of multiple teaching approaches, and adequate training time were critical to significant improvement.
Agbar F, Zhang S, Wu Y, et al. Nurse Educ Pract. 2023;67:103565.
… AHRQ Hospital Survey of Patient Safety Culture (HSOPS), a culture of blame remained a pervasive problem despite improvements in other components … safety culture in many hospitals. … Agbar F,  Zhang S, Wu Y, et al. Effect of patient safety education interventions …
Vanhaecht K, Seys D, Russotto S, et al. Int J Environ Res Public Health. 2022;19:16869.
… continuing psychological harm after involvement in a medical error or adverse event. In this study, an expert … of ‘second victim’ in the literature and proposed a new consensus-based definition. … Vanhaecht K, Seys D, … evidence and consensus-based definition of second victim: a strategic topic in healthcare quality, patient safety, …
Trout KE, Chen L-W, Wilson FA, et al. Int J Environ Res Public Health. 2022;19:12525.
Electronic health record (EHR) implementation can contribute to safe care. This study examined the impact of EHR meaningful use performance thresholds on patient safety events. Researchers found that neither full EHR implementation nor achieving meaningful use thresholds were associated with a composite patient safety score, suggesting that hospitals may need to explore ways to better leverage EHRs and as well other strategies to improve patient safety, such as process improvement and staff training.
Wu G, Podlinski L, Wang C, et al. Jt Comm J Qual Patient Saf. 2022;48:665-673.
… among healthcare teams. This study evaluated the impact of a one-hour interdisciplinary in situ simulation training on … in technical skills of individuals and teams (e.g., CPR-related technical skills). … Wu G, Podlinski L, Wang C, et al. Intraoperative code blue: …
Fawzy A, Wu TD, Wang K, et al. JAMA Intern Med. 2022;182:730-738.
Black and brown patients have experienced disproportionately poorer outcomes from COVID-19 infection as compared with white patients. This study found that patients who identified as Asian, Black, or Hispanic may not have received timely diagnosis or treatment due to inaccurately measured pulse oximetry (SpO2). These inaccuracies and discrepancies should be considered in COVID outcome research as well as other respiratory illnesses that rely on SpO2 measurement for treatment.
McDonald EG, Wu PE, Rashidi B, et al. JAMA Intern Med. 2022;182:265-273.
Deprescribing is one intervention to reduce the risk of adverse drug events, particularly in older adults and people taking five or more medications. In this cluster randomized trial, older adults (≥65 years) taking at least five medications at hospital admission were randomly assigned to intervention (personalized reports of deprescribing opportunities) or control. Despite an increase in deprescribing in both groups, there was no difference in adverse drug events or adverse drug withdrawal events.
Vaughan CP, Hwang U, Vandenberg AE, et al. BMJ Open Qual. 2021;10:e001369.
Prescribing potentially inappropriate medications (such as antihistamines, benzodiazepines, and muscle relaxants) can lead to adverse health outcomes. The Enhancing Quality of Prescribing Practices for Older Adults in the Emergency Department (EQUIPPED) program is a multicomponent intervention intended to reduce potentially inappropriate prescribing among older adults who are discharged from the emergency department. Twelve months after implementation at three academic health systems, the EQUIPPED program significantly reduced overall potentially inappropriate prescribing at one site; the proportion of benzodiazepine prescriptions decreased across all sites.
Gleason KT, Commodore-Mensah Y, Wu AW, et al. Nurse Educ Today. 2021;104:104984.
… online open courses (MOOCs) have the ability to reach a broad audience of learners. The Science of Safety in … learning format. … Gleason KT, Commodore-Mensah Y, Wu AW, et al. Massive open online course (MOOC) learning … competence for patient safety among global learners: a prospective cohort study. Nurse Educ …
Bulliard J‐L, Beau A‐B, Njor S, et al. Int J Cancer. 2021;149:846-853.
Overdiagnosis of breast cancer and the resulting overtreatment can cause physical, emotional, and financial harm to patients. Analysis of observational data and modelling indicates overdiagnosis accounts for less than 10% of invasive breast cancer in patients aged 50-69. Understanding rates of overdiagnosis can assist in ascertaining the net benefit of breast cancer screening.
Geerts JM, Kinnair D, Taheri P, et al. JAMA Netw Open. 2021;4:e2120295.
The COVID-19 pandemic has disrupted many aspects of health care delivery and has placed unprecedented pressure on health care workers. This consensus statement, based on input from an international panel of individuals with expertise in health leadership, health care, and public health, outlines 10 imperatives to guide health and public leaders during the post emergency stage of the pandemic. Imperatives addressed in the framework include supporting staff well-being and psychological health, preparing for future emergencies, managing the backlog of delayed care, and the importance of sustaining learning, innovations and collaborations that arose during the pandemic.
Wu AW, Vincent CA, Shapiro DW, et al. J Patient Saf Risk Manag. 2021;26:93-96.
… J Patient Saf Risk Manag … The July effect is a phenomenon that presumably results in poor care due to the … active, independent practice . The authors discuss how a systemic approach is required to situate these practitioners to provide the safest care possible. … Wu AW, Vincent C, Shapiro DW, et al. Mitigating the July …
Busch IM, Moretti F, Campagna I, et al. Int J Environ Res Public Health. 2021;18:5080.
… and lack of financial resources. Findings indicate a need for implementing new second victim support programs, … healthcare providers facing the burden of adverse events: a systematic review of second victim support resources. Int J …
Wu F, Dixon-Woods M, Aveling E-L, et al. Soc Sci Med. 2021;280:114050.
Reluctance of healthcare team members to speak up about concerns can hinder patient safety. The authors conducted semi-structured interviews with 165 participants (health system leadership, managers, healthcare providers, and staff) about policies, practice, and culture around voicing concerns related to quality and safety. Findings suggest that both formal and informal hierarchies can undermine the ability and desire of individuals to speak up, but that informal organization (such as personal relationships) can motivate and support speaking up behaviors.