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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 - 11 of 11 Results
Albutt AK, Ramsey L, Fylan B, et al. Health Expect. 2023;26:1467-1477.
Patients' healthcare-seeking behaviors changed during the COVID-19 pandemic, particularly during the first wave. This longitudinal study sought patient perspectives about their experiences accessing healthcare, activities they undertook to keep themselves and others safe, and their understanding of healthcare system resilience and resources. Three themes emerged: a "new safety normal," existing vulnerabilities and heightened safety, and "are we all in this together?" The study highlighted that preexisting gaps in care experienced by those with chronic conditions or other vulnerabilities widened during the pandemic and deserve further research.
Halligan D, Janes G, Conner M, et al. J Patient Saf. 2023;19:143-150.
Reducing low-value tests and treatments has been a focus of patient safety efforts, but less attention has been focused on low-value patient safety practices (PSP). This study describes the concept of “safety clutter” and understanding which PSP are of low-value, ineffective, and could be discontinued. Frequently cited PSP included paperwork, duplication, and intentional rounding.
Brierley-Jones L, Ramsey L, Canvin K, et al. Res Involv Engagem. 2022;8:8.
Patient engagement in safety efforts is encouraged, but patients are less often included as active participants in designing patient safety interventions. This review identified 52 studies that included mental health patients in the design, delivery, implementation, and/or evaluation of patient safety research. The authors argue that increased inclusion of patients in safety research may lead to development of higher quality safety interventions.
Ramsey L, Albutt AK, Perfetto K, et al. Int J Equity Health. 2022;21:13.
Patients with learning disabilities encounter unique patient safety threats. This qualitative study explored the care experiences and safety concerns of people with learning disabilities and their caregivers. Researchers identified several protective factors to avoid safety inequities and support safe, high-quality care, including access to social support and advocacy, appropriate staffing, sufficient expertise in care settings, care continuity, and accommodations of individualized care and communication needs.
Louch G, Albutt AK, Harlow-Trigg J, et al. BMJ Open. 2021;11:e047102.
Prior research found that patients with learning disabilities (e.g., autism, attention deficit disorder, Down’s syndrome) face numerous patient safety threats. In this narrative review, the authors synthesized academic and grey literature exploring patient safety outcomes for individuals with learning disabilities in acute care settings. Findings suggest that individuals with learning disabilities experience poorer patient outcomes but that increasing family and caregiver engagement as well as provider understanding of the needs of people with learning disabilities can improve outcomes.
Albutt AK, Berzins K, Louch G, et al. nt J Ment Health Nurs. 2021;30:798-810.
The UK’s National Health System has faced gaps in mental health care delivery affecting patient safety. Interviews with 14 mental health professionals identified several factors associated with patient safety in mental health service settings including safety culture, communication systems, service user factors, service process, and staff workload. Interventions to improve patient safety in mental health settings should be developed with these factors in mind.
Berzins K, Baker J, Louch G, et al. Health Expect. 2020;23:549-561.
This qualitative study interviewed patients and caregivers about their experiences and perceptions of safety within mental health services. These interviews identified a broad range of safety issues; the authors suggest that patient safety in mental health services could be expanded to include harm caused trying to access services and self-harm provoked by contact with, or rejection from, services.
Louch G, Mohammed MA, Hughes L, et al. Health Expect. 2019;22:102-113.
The Patient Reporting and Action for a Safe Environment (PRASE) study was a large patient engagement intervention that proactively solicited hospitalized patient feedback about their safety. This qualitative study found that hospital volunteers could use PRASE tools to sustainably solicit patient feedback in place of paid study staff. However, health care workers did not consistently have means to act upon the safety hazards that patients and volunteers identified. A recent PSNet interview with Rebecca Lawton, lead investigator on the PRASE study, discussed her experience and insights in patient engagement research.
Louch G, O'Hara JK, Mohammed MA. Health Expect. 2017;20:1143-1153.
This qualitative evaluation found that a volunteer-administered patient engagement intervention was received positively by patients, families, volunteers, and frontline staff. The authors suggest that this intervention is a promising approach to enhance patient engagement.
Albutt AK, O'Hara JK, Conner MT, et al. Health Expect. 2017;20:818-825.
This systematic review examined whether patient and family member activation of rapid response teams improved recognition of clinical deterioration. Studies demonstrated that patients and family members did not overwhelm rapid response capacity with frequent activations, but they did activate rapid response to convey concerns beyond clinical deterioration. The authors suggest further study is needed to determine how to best engage patients and families to detect clinical deterioration early.