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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 39 Results
Zhang D, Gu D, Rao C, et al. BMJ Qual Saf. 2023;32:192-201.
Clinician workload has been linked with poor patient outcomes. This retrospective cohort study assessed the outcomes for patients undergoing coronary artery bypass graft (CABG) performed as a surgeons’ first versus non-first procedure of the day. Findings suggest that prior workload adversely affected outcomes for patients undergoing CABG surgery, with increases in adverse events, myocardial infarction, and stroke compared to first procedures.

Uttaro E, Zhao F, Schweighardt A. Int J Pharm Compd. 2021;25(5):364-371. 

Medication administration, particularly when it involves drug formulation manipulation, is a complex process. This study analyzed the products included on the Institute for Safe Medication Practices’ (ISMP) ‘Do Not Crush List’ and found that many presented no risk or low risk for crushing. The authors provide recommendations for clinicians to aid in clinical decision-making regarding crushing, such as suitable personal protective equipment and prompt administration.
Quach ED, Kazis LE, Zhao S, et al. BMC Health Serv Res. 2021;21:842.
The safety climate in nursing homes influences patient safety. This study of frontline staff and managers from 56 US Veterans Health Administration community living centers found that organizational readiness to change predicted safety climate. The authors suggest that nursing home leadership explore readiness for change in order to help nursing homes improve their safety climate.
Shao Q, Wang Y, Hou K, et al. J Adv Nurs. 2021;77:4005-4016.
Patient suicide in all settings is considered a never event. Nurses caring for the patient may experience negative psychological symptoms following inpatient suicide. This review identified five themes based on nurses’ psychological experiences: emotional experience, cognitive experience, coping strategies, self-reflection, and impact on self and practice. Hospital administrators should develop education and support programs to help nurses cope in the aftermath of inpatient suicide.  
Quach ED, Kazis LE, Zhao S, et al. J Am Med Dir Assoc. 2021;22:388-392.
This cross-sectional study examined the impact of safety climate on adverse events occurring in Veterans Administration (VA) nursing homes and community living centers. Survey results suggest that nursing homes may reduce adverse events by increasing supportive supervision and a safer physical environment. The survey found that supervisor commitment to safety was associated with lower rates of major injuries from falls and catheter use, and that environmental safety was associated with lower rates of pressure ulcers, major injuries from falls, and catheter use.
Zhao Z, Bai H, Duan J, et al. Thorac Cancer. 2020.
The COVID-19 pandemic is negatively impacting patients with non-COVID-related disease and providers are being faced with challenges in delivering ongoing care to patients with chronic health conditions, such as cancer. This article provides recommendations for alternative treatment for lung cancer patients undergoing chemotherapy and other targeted therapies. The authors also suggest approaches to managing treatment-related adverse events outside the hospital to reduce virus exposure among an immunocompromised population.

Chui MA, Pohjanoksa-Mäntylä M, Snyder ME, eds. Res Social Adm Pharm. 2019;15(7):811-906.

Medication safety is a worldwide challenge. This special issue discusses factors affecting the reliability of the ordering, dispensing, and administration of medications across a range of environments. Articles cover topics such as the need to deepen understanding of safety in community pharmacies, the use of smart pumps for high-alert medications, and the international effort to reduce medication-related harm.
Zacher JM, Cunningham FE, Zhao X, et al. Am J Health-Syst Pharm. 2018;75:1460-1466.
Look-alike and sound-alike medications are known to increase the risk of adverse drug events. Using Veterans Affairs administrative data on prescriptions filled for look-alike and sound-alike medications, researchers found that the potential for medication errors was high, but the actual error rate based on chart review was low.
Doctor JN, Nguyen A, Lev R, et al. Science. 2018;361:588-590.
High-risk opioid prescribing by providers contributes to opioid misuse. Prior studies have shown that patients frequently receive opioid prescriptions even if they have a history of overdose. In this randomized trial involving 861 providers prescribing opioids to 170 patients who experienced fatal overdose, providers in the intervention arm were notified about patients' deaths by the county medical examiner while those in the control arm were not. Researchers found that milligram morphine equivalents prescribed to the patients of providers who received the death notifications decreased by almost 10% in the 3-month period following the intervention. There were no significant changes in the prescribing patterns of the control group. An Annual Perspective discussed patient safety and opioid medications.
Gipson DS, Kirkendall E, Gumbs-Petty B, et al. Pediatrics. 2017;139.
Taxonomies help to consistently organize data and evidence for use in research. This commentary describes the development of a terminology specific to adverse events in children for use in various settings. The authors note that the tool will be continuously updated and is expected to mature over time.
Ferrús L, Silvestre C, Olivera G, et al. J Patient Saf. 2016;17:36-43.
This qualitative study examined perceptions of nurse and physician quality management leaders about what clinicians experience after being involved in adverse events. Participants acknowledged the emotional impact of adverse events on clinicians and the need for formal mechanisms to offer support to second victims.
Elwy R, Itani KMF, Bokhour BG, et al. JAMA Surg. 2016;151:1015-1021.
Even though disclosure of medical errors reduces litigation and patient distress, many providers remain uncomfortable with disclosing and apologizing for errors. In this survey of 67 surgeons across 3 medical centers, most reported prompt disclosure of adverse events. Surgeons who had difficult disclosure conversations experienced more anxiety. These results highlight the continued importance of supporting providers who experience emotional distress after medical errors.
Mira JJ, Lorenzo S, Carrillo I, et al. BMC Health Serv Res. 2015;15:341.
This survey of health care organizations found that most reported having inadequate support for second victims. Many organizations lacked protocols for responding to serious adverse events, especially in primary care. These results underscore the importance of implementing safety initiatives to address health care providers' needs following adverse events.
Mao X, Jia P, Zhang L, et al. PLoS One. 2015;10:e0129948.
Human factors engineering has been increasingly applied in health care. This systematic review found that while human factors engineering interventions often improved health care worker outcomes and patient safety, most studies were of moderate or low quality and few considered the relevant costs of the programs.
Wang H-F, Jin J-F, Feng X-Q, et al. Ther Clin Risk Manag. 2015;11:393-406.
A hospital in the People's Republic of China was able to achieve a significant reduction in medication administration errors through a multidisciplinary quality improvement effort. The initiative included organizational measures, information technology interventions, quality improvement tools, and process optimization.

Ohno-Machado L, ed. J Am Med Inform Assoc. 2014;21:e180-e375.

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Levy SM, Senter CE, Hawkins RB, et al. Surgery. 2012;152:331-6.
Poor adherence to individual elements of a surgical safety checklist was noted in this study conducted at a tertiary care children's hospital. The authors attributed this finding to poor implementation and dissemination of the checklist.
Ahuja N, Zhao W, Xiang H. Pediatrics. 2012;130:e786-e793.
Pediatric inpatients with chronic medical conditions had significantly higher rates of iatrogenic medical errors in this study, which analyzed the AHRQ-sponsored Kids' Inpatient Database. Nearly half of the pediatric inpatients in this large national sample had at least one chronic medical condition, and among these patients, the overall medical error rate was almost four times higher than the rate among children without chronic medical conditions. This association remained statistically significant after adjusting for patient and hospital characteristics, disease severity, and length of stay. The association between medical complexity and the risk of preventable harm while hospitalized has also been demonstrated in adult inpatients.