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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 106 Results
Adapa K, Ivester T, Shea CM, et al. Jt Comm J Qual Patient Saf. 2022;48:642-652.
Tiered huddle systems (THS) include staff at all levels of the organization- frontline healthcare workers, managers, directors, and executives- and have been shown to increase adverse event reporting and improve safety culture. This US health system implemented a three-level THS in hospital and ambulatory settings to increase event reporting. Based on an interrupted time series analysis, reporting increased for total safety events, including near misses.

Leape LL. Cham, Switzerland: Springer Nature; 2021. ISBN: 9783030711252.

The publication of “Error in Medicine” by Dr. Lucian Leape marked a pivotal step in the launch of the modern patient safety movement. In this publication, Dr. Leape shares insights stemming from his notable career in safety to outline milestones in the current effort to reduce patient harm due to medical mistakes.
Polancich S, Hall AG, Miltner RS, et al. J Healthc Qual. 2021;43:137-144.
The COVID-19 pandemic has disrupted many aspects of health care delivery, including how hospitals prevent common hospital-acquired conditions such as pressure injuries. Based on retrospective data, the authors of this study did not identify a longitudinal increase in hospital-acquired pressure injuries between March and July 2020. The authors discuss how prior organizational efforts to reduce hospital-acquired pressure injuries allowed their hospital to quickly adapt existing workflows and processes to respond to the COVID-19 pandemic.
Zhang T, Mosier J, Subbian V. JMIR Hum Factors. 2021;8:e24860.
The increased use of telehealth during the COVID-19 pandemic has not been without challenges. This article uses the Systems Engineering Initiative for Patient Safety (SEIPS) model to assess barriers related to telehealth implementation during the pandemic and the impact on patients, providers, technology, care processes, organizations, and the environment.
Orenstein EW, Ferro DF, Bonafide CP, et al. JAMIA Open. 2019;2(3):392-398.
Handoffs represent a vulnerable time for patients when lapses in communication may adversely impact safety. Prior research has shown that medication errors occur frequently among patients transferred from ICU to non-ICU locations within the same hospital. In this qualitative study, physicians reviewed transfer notes and handoff documents for 50 patients transferred from a pediatric ICU to a medical unit. They found clinically relevant differences between the handoff and transfer note documentation in 42% of the transfers and conclude that such discrepancies are both common and place patient safety at risk. A previous WebM&M commentary described an adverse event related to a patient handoff.
Basner M, Asch DA, Shea JA, et al; iCOMPARE Research Group. N Engl J Med. 2019;380:915-923.
… training during residency. … Basner M, Asch DA, Shea JA, et al; iCOMPARE Research Group. N Engl J Med. … … SV … AL … J. … DM … JT … DW … O. … JH … DS … KG … CG … S. … DJ … DF … Basner … Asch … Shea … Bellini … Carlin … … Even‑Shoshan … JH Silber … DS Small … KG Volpp … CG Mott … S. Coats … DJ Mollicone … DF Dinges …
Silber JH, Bellini LM, Shea JA, et al; iCOMPARE Research Group. N Engl J Med. 2019;380:905-914.
Duty hour reform for resident physicians was implemented as a patient safety measure, but it remains controversial. The iCOMPARE study is a cluster-randomized noninferiority trial in which 63 internal medicine programs were assigned either to follow the 2011 duty hour rules or to maintain flexible resident schedules. Researchers found no significant differences in 30-day mortality or AHRQ patient safety indicators among programs with fixed versus flexible resident schedules, similar to a recent study of surgical trainees. Programs with flexible schedules had slightly higher 30-day readmission rates and higher incidence of prolonged length of stay. Overall, the authors conclude that local flexibility in resident schedules did not adversely affect patient safety. An accompanying editorial calls for eliciting patient perspectives about trainee duty hours and the therapeutic relationship between rotating physicians and the hospitalized patient. A previous PSNet interview discussed the FIRST trial, which examined how less restrictive duty hours affected patient outcomes and resident satisfaction.
Sellers MM, Berger I, Myers JS, et al. J Surg Educ. 2018;75:e168-e177.
This qualitative study examined incident reports about surgical patients, comparing trainee reports to those submitted by attending surgeons and nurses. Trainees were more likely to enter reports anonymously and completed more elements for each report, but they also used more blame language and submitted fewer reports overall. The results suggest that encouraging trainee reporting may shed light on surgical safety.
Ward ME, De Brún A, Beirne D, et al. Int J Environ Res Public Health. 2018;15:E1182.
Change initiatives require broad-based collective design strategies to ensure the range of needs are addressed. This commentary explains how one hospital group used codesign methods to engage leadership in a teamwork and culture improvement project. The authors describe specific tools and tactics used to implement the work and summarize the value of the approach for other health care organizations.
Gandhi TK, Kaplan GS, Leape L, et al. BMJ Qual Saf. 2018;27:1019-1026.
… & safety … BMJ Qual Saf … Over the last decade, the Lucian Leape Institute has explored five key areas in health care to … , Dr. Tejal Gandhi, president of the IHI/NPSF Lucian Leape Institute, discussed improving patient safety at a …
Shea KM, Hobbs AL, Shumake JD, et al. Am J Health Syst Pharm. 2018;75:876-885.
This pre–post analysis found a significant drop in medication error rates after implementation of an antibiotic stewardship program. The authors attribute this improvement to pharmacist medication review, which has been shown to enhance medication safety across multiple settings.
Desai SV, Asch DA, Bellini LM, et al. New Engl J Med. 2018;378:1494-1508.
Duty hour reform for trainees was undertaken to improve patient safety. However, experts have raised concerns that duty hour limits have reduced educational opportunities for trainees. This study randomized internal medicine residency programs to either standard duty hour rules from the Accreditation Council on Graduate Medical Education (ACGME) or less stringent policies that did not mandate the maximum shift length or time off between shifts. Investigators found that trainees in both groups spent similar amounts of time in direct patient care and educational activities, and scores on examinations did not differ. Interns in flexible duty hour programs reported worse well-being and educational satisfaction compared to those working within standard duty hours. As in a prior study of surgical training, program directors of flexible duty hour programs reported higher satisfaction with trainee education. These results may help allay concerns about detrimental effects of duty hour reform on graduate medical education. A PSNet perspective reviewed changes to the ACGME requirements to create flexibility for work hours within the maximum 80-hour workweek.

Jt Comm J Qual Patient Saf. 2017;43:315-337.

… Campbell M: Mahoney D … CM … L. … AJ … ND … DC … TC … CPS. … AK … J. … P. … T. … T. … R. … Clancy … Becker … Starmer … Spector … West … Sectish … Landrigan … Anderson … Muther … Nevin … Resnik … Salam … …
Chicago, IL: American College of Healthcare Executives, National Patient Safety Foundation's Lucian Leape Institute; 2017.
… Healthcare Executives, National Patient Safety Foundation's Lucian Leape Institute; 2017. … American College of Healthcare Executives; ACHE; Lucian Leape Institute of the National Patient Safety Foundation; LLI …
Ban KA, Chung JW, Matulewicz RS, et al. J Am Coll Surg. 2016;224.
Analyzing data from a prior trial of flexible versus traditional duty hours, this study found that female residents perceived patient safety as worse than male residents. Changes in duty hours had mixed effects on these self-reported outcomes and seemed to exacerbate gender differences. The authors recommend further study to determine how to improve learning for trainees regardless of gender.

J Am Coll Surg. 2017;224:103-159.

… … KA … JW … RS … RR … JA … AR … CM … AD … KY … R. … R. … L. … T. … DB … FR … DB … JF … JK … DD … JJ … ES … ME … CY … Ban … Chung … Matulewicz … Kelz … Shea … Dahlke … Quinn … Yang … Bilimoria … Rajaram … Love … … … Ko … KA Ban … JW Chung … RS Matulewicz … RR Kelz … JA Shea … AR Dahlke … CM Quinn … AD Yang … KY Bilimoria … R. …