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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 - 17 of 17 Results
Suclupe S, Kitchin J, Sivalingam R, et al. J Patient Saf. 2023;19:117-127.
Patient identification mistakes can have serious consequences. Using the Systems Engineering for Patient Safety (SEIPS) framework, this qualitative study explored systems factors contributing to patient identification errors during intrahospital transfers. The authors found that patient identification was not completed according to hospital policy during any of the 60 observed patient transfer handoffs. Miscommunication and lack of key patient information were common factors contributing to identification errors.
Sutton E, Booth L, Ibrahim M, et al. Qual Health Res. 2022;32:2078-2089.
Patient engagement and encouragement to speak up about their care can promote patient safety. This qualitative study explored patients’ psychosocial experiences after surviving abdominal surgery complications. Findings highlight an overarching theme of vulnerability and how power imbalances between patients and healthcare professionals can influence speaking up behaviors.
Vollam S, Gustafson O, Morgan L, et al. Crit Care Med. 2022;50:1083-1092.
This mixed-method study explored the reasons why out-of-hours discharges from the ICU to the ward, and nighttime coverage are associated with poor outcomes. Based on qualitative interviews with patients, family members, and staff involved in the ICU discharge process, this study found that out-of-hours discharges are considered unsafe due to nighttime staffing levels and skill mix. Out-of-hours discharges often occurred prematurely, without adequate handovers, and involved patients who were not physiologically stable, and at risk for clinical deterioration.
Vollam S, Gustafson O, Young JD, et al. Crit Care. 2021;25:10.
Patients transferred out of the intensive care unit (ICU)may be at risk for adverse events.Results from this multi-site retrospective case review suggest that the proportion of potentially avoidable in-hospital deaths is higher in patients discharged from the ICU compared to the hospital-wide population. Common problems identified include out-of-hours discharge from the ICU, suboptimal rehabilitation, absent nutritional planning, and incomplete sepsis management.  
Morgan L, Benson D, McCulloch P. BMJ. 2019;364:l1037.
Investigations into medical mistakes that result in patient harm should be fair, complete, and consider the context of the event. This commentary examines investigation processes in the United Kingdom and highlights the importance of understanding how human factors contribute to error to help effectively assess each incident and support transparency and improvement.
Walker S, Mason A, Quan P, et al. Lancet. 2017;390:62-72.
The weekend effect (higher mortality for patients in acute care settings on weekends compared to weekdays) has led to widespread concerns about hospital staffing. This retrospective study examined whether mortality for emergency admissions at four hospitals in the United Kingdom differed on weekends compared to weekdays. Unlike prior studies of the weekend effect, this study included multiple specific markers of patients' illness severity as well as hospital workload. Investigators found higher mortality associated with being admitted to the hospital during weekends compared to weekdays, but a significant proportion of the observed weekend effect was explained by severity of patient illness. They used three measures to approximate hospital workload: total number of admissions, net admissions (subtracting discharges from admissions), and percentage of beds occupied. None of these workload measures was associated with mortality. The authors conclude that differences in illness severity rather than health care team staffing explain the weekend effect. A recent PSNet interview discussed the weekend effect in health care.
Flynn LC, McCulloch P, Morgan LJ, et al. Ann Surg. 2016;264:997-1003.
This qualitative study sought to validate and understand the previously published results of the Safer Delivery of Surgical Services (S3) program, which showed that combining efforts aimed at improving the work system and safety culture was more efficacious than either approach alone. The investigators developed themes and lessons learned through semistructured interviews with hospital staff and the research team.
McCulloch P, Morgan L, New S, et al. Ann Surg. 2015;265.
Safety culture and work systems influence safety, but it is unclear whether safety improvement efforts should focus on one or both factors. This study sought to improve adherence to the WHO surgical safety checklist and to enhance technical and nontechnical team performance using several safety interventions. One intervention focused on improving safety culture, while another was directed at the work system. Investigators also tested a combined approach. Although both team training and system redesign individually demonstrated improvement, the combined approach was more successful than either individual approach. This finding suggests that in order to truly enhance surgical safety, organizations must invest in both systems and culture interventions.
Morgan L, Pickering S, Hadi M, et al. BMJ Qual Saf. 2015;24:111-9.
An intervention that combined teamwork training with efforts to standardize certain operative procedures resulted in increased adherence to the World Health Organization safe surgery checklist and improved communication within the operating room. No effect was found on clinical outcomes, but the study was likely too small to detect such an impact.
Morgan L, New S, Robertson ER, et al. BMJ Qual Saf. 2015;24:120-7.
Standard operating procedures, or SOPs, are a key tenet of human factors engineering. This time-series analysis found that implementing SOPs in the operating room did not change either surgical process outcomes, such as adherence to the WHO surgical checklist, or clinical outcomes. These results emphasize the challenge of applying systems solutions in clinical settings.
Robertson ER, Morgan L, Bird S, et al. BMJ Qual Saf. 2014;23:600-7.
Every day the care of hospital patients is handed off from clinician to clinician, creating serious risks for patient safety. The Joint Commission and the Accreditation Council for Graduate Medical Education have called for institutions to implement standardized handoff strategies. However, despite mandates to create safer handoffs, this systematic review found a lack of reliable strategies to improve clinical handoff outcomes. The literature search uncovered 29 relevant handoff studies, only 2 of which were randomized controlled trials. The studies took varied approaches to intervention design and outcome measurement. The quality of most studies was poor, with the majority representing small, uncontrolled, unblinded before-and-after comparisons. The authors of this review call for establishing a common taxonomy to better classify handoffs, improvement methods, and outcomes. Dr. Vineet Arora discussed the challenges of handoffs in a prior AHRQ WebM&M interview.
Catchpole K, Sellers R, Goldman A, et al. Qual Saf Health Care. 2010;19:318-22.
Transfer of patients from the operating room to intensive care involves exchange of complex information between multiple providers in a short period of time.  In an innovative effort to apply principles from other industries to medicine, this study used interviews with the managers of Formula One auto racing teams to determine the key elements of racing "pit stops" and draw lessons for improving the safety of the postoperative handover process. The key lessons learned from the auto racing approach—proactive planning, active management of the handover process using information technology, and post hoc learning by data monitoring and analysis—have subsequently been applied to standardize and improve the postoperative handover process.
Kreckler S, Catchpole K, New SJ, et al. Ann Surg. 2009;250:1035-40.
This study found that compliance with specific care processes was poor and that risk for adverse events increased with longer hospitalizations and after a surgical intervention. The authors advocate for continued observation of process measures and incorporation of Toyota-type system changes.