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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 380 Results
Loo VC, Kim S, Johnson LM, et al. J Patient Saf. 2023;19:460-464.
Ensuring the safety of clinical trial participants is paramount to successful, meaningful clinical research. In this study, researchers examined 585 clinical trial documents and found that 17% included potential patient safety interventions (e.g., resolving medication dosing discrepancies). The authors suggest that clinical specialists’ review of study protocol documents could enhance patient safety during clinical trial conduct.
Dunbar EG, Massey AC, Lee YL, et al. Am Surg. 2023;89:3272-3274.
Medication reconciliation is an important care process anytime a patient transitions from one care setting to another, including emergency department to hospital admission. This study sought to determine the incidence of completed medication reconciliation for admitted trauma patients and the number of identified discrepancies. Of the 89 patients included in the study, more than a quarter did not receive an admission medication reconciliation (AMR), and of those with an AMR, 48% had at least one unintended discrepancy, indicating the importance of completing medication reconciliation for all admitted trauma patients.
McMullen S, Panagioti M, Planner C, et al. Health Expect. 2023;26:2064-2074.
Caregivers and family members offer a unique perspective on patient safety. In this study, patient and caregiver stakeholders outlined the safety threats affecting patients discharged from mental health services and the well-being of caregivers as well as potential solutions. Participants highlighted approaches to improve caregiver involvement, patient and caregiver wellness and education, and the policy and system environments.
Johnson EA, Dudding KM, Carrington JM. Nurs Inq. 2023;Epub Jul 17.
Research on artificial intelligence (AI) in medicine is rapidly increasing including AI in nursing care. In this commentary, the authors describe the challenges of using AI in healthcare and the unique implications for nursing practice and policy. In particular, nurses should be involved in the development and testing of any AI used in the nursing process.

Abraham J, Rosen M, Greilich PE eds. Jt Comm J Qual Patient Saf. 2023;49(8):341-434.

… , teamwork science , and artificial intelligence . … Abraham J, Rosen M, Greilich PE eds. Jt Comm J Qual Patient Saf . … … JMJJ … E … HG … MB … CB … K … T … FK … JL … B … A … C … K … D … CC … M … EH … MB … PE … AV … AM … ML … …
Watterson TL, Steege LM, Mott DA, et al. Jt Comm J Qual Patient Saf. 2023;49:485-493.
Occupational fatigue (e.g., stress, physical fatigue) can have deleterious effects on patients, staff, and health systems. This article describes a conceptual framework to better understand the factors contributing to occupational fatigue and downstream implications (e.g., poor patient safety, employee burnout, lower retention, and higher turnover).
Lainidi O, Jendeby MK, Montgomery A, et al. Front Psychiatry. 2023;14:111579.
Encouraging frontline healthcare workers to voice concerns is an important component of safety culture. This systematic review of 76 qualitative studies explored how speaking up behaviors and silence are measured in healthcare. The authors identified several evidence gaps, including a reliance on self-reported data and overrepresentation of certain demographic characteristics.
Perspective on Safety June 14, 2023
… emergencies. References Carman KL, Dardess P, Maurer M, et al. Patient And Family Engagement: A Framework For … doi:10.1136/qshc.2009.036954 Perkins SB, Dokken DL, Johnson BH, Frederick K. Family Presence During Covid-19: … . 2022;9(1):62-71. doi:10.35680/2372-0247.1661 Merner B, Schonfeld L, Virgona A, et al. Consumers’ and health …

This piece discusses how family presence and participation in healthcare at all levels can improve patient safety as well as how the COVID-19 pandemic affected partnership with patients and families, ultimately highlighting the critical importance of family presence and participation.

Beverley H. Johnson

Beverley H. Johnson is the president and CEO of the Institute for Patient- and Family-Centered Care (IPFCC). We spoke to her about her experience in patient and family engagement and improving patient safety, including how to continue to partner with families during pandemics and through technology.

Sparling J, Hong Mershon B, Abraham J. Jt Comm J Qual Patient Saf. 2023;49:410-421.
Multiple handoffs can occur during perioperative care, which can increase the risk for errors and patient harm. This narrative review summarizes research on the benefits, limitations, and implementation challenges of electronic tools for perioperative handoffs and the role of artificial intelligence (AI) and machine learning (ML) in perioperative care.
Schneider P, Lorenz A, Menegay MC, et al. Am J Obstet Gynecol MFM. 2023;5:100912.
Reducing maternal morbidity and mortality continues to be a patient safety priority in the United States. The article describes the implementation of a quality improvement initiative in Ohio to improve outcomes for patients with a severe hypertensive event during pregnancy or postpartum. Among 29 participating hospitals between July 2020 and September 2021, the researchers identified sustained improvements in timely and appropriate treatment for severe hypertension, timely follow-up appointment after hospital discharge, and patient education about urgent maternal warning signs across both non-Hispanic Black and White pregnant or postpartum people.
Boudreaux ED, Larkin C, Vallejo Sefair A, et al. JAMA Psych. 2023;80:665-674.
Patients who present to the emergency department (ED) with suicidal ideation can benefit from ED-initiated interventions, but interventions can be difficult to implement and maintain. This research builds on a 2013 study, describing the quality improvement (QI) methods used to implement the Emergency Department Safety Assessment and Follow-up Evaluation 2 (ED-SAFE 2) trial. The QI approach was successful in reducing death by suicide and suicide-related acute care during the study period.
Mortsiefer A, Löscher S, Pashutina Y, et al. JAMA Netw Open. 2023;6:e234723.
Polypharmacy among older adults can cause adverse health outcomes as well as adversely impact social outcomes, medication management, and healthcare utilization. The COFRAIL cluster randomized trial explored whether family conferences can promote deprescribing and reduce adverse outcomes related to polypharmacy in community-dwelling frail older adults. After 12 months of follow-up, the researchers did not find any significant difference in hospitalizations among patients randomized to family conferences or usual care. The number of potentially inappropriate prescriptions decreased among patients randomized to family conferences at 6-month follow-up, but this reduction was not sustained at the 12-month follow-up.
Edwards SE, Class QA, Ford CE, et al. Am J Obstet Gynecol MFM. 2023;5:100927.
… Am J Obstet Gynecol MFM … Racial bias negatively impacts … same scenarios with the only difference being the patient's race (i.e., Black or white). No significant racial biases …
Ward CE, Taylor M, Keeney C, et al. Prehosp Emerg Care. 2023;27:263-268.
Weight-based calculation errors and lack of weight documentation can lead to medication errors in pediatric patients. This analysis of Maryland emergency medical services (EMS) data including children who received a weight-based medication found that weight documentation was associated with a small but significantly lower rate of medication dose errors, particularly among infants and for epinephrine and fentanyl doses.
King CR, Shambe A, Abraham J. JAMIA Open. 2023;6:ooaf015.
Handoffs and transitions of care represent a vulnerable time for patients as important information must be shared and understood by multiple people. This study focuses on postoperative nurse handoffs, specifically regarding situational awareness and anticipatory guidance, and the role artificial intelligence (AI) could play in improving handoffs. Five themes were uncovered, including the importance of situational awareness and associated barriers, how AI could address those barriers, and how AI could result in new/additional barriers.
Abraham J, Duffy C, Kandasamy M, et al. Int J Med Inform. 2023;174:105038.
Multiple handoffs occur during the perioperative period, each presenting an opportunity for miscommunication and patient harm. This review uses the Systems Engineering Initiative for Patient Safety (SEIPS) framework to describe the barriers and enablers for improving staff communication pre-, intra-, and post-operative handoffs. Structured hand-offs, checklists, protocols, and interprofessional teamwork were cited as enablers for improved communication.
Gross TK, Lane NE, Timm NL, et al. Pediatrics. 2023;151:e2022060971-e2022060972.
Emergency room crowding is a persistent factor that degrades safety for patients of all ages. This collection provides background, best practices, and recommendations to reduce emergency department crowding and its negative impact on pediatric care. The publications examine factors that influence crowding and improvement at the input, departmental, and hospital/outpatient stages of emergency care.
Holland R, Bond CM, Alldred DP, et al. BMJ. 2023;380:e071883.
Careful medication management in long-term care residents is associated with improved hospital readmission rates and reduced fall rates. In the UK, pharmacist independent prescribers (PIP) can initiate, change, or monitor medications, and this cluster randomized controlled trial evaluated the effect of PIPs on fall rates. After six months of PIP involvement, fall rates (the primary outcome) were not statistically different than the usual care group, although drug burden was reduced.