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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 21 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.
Peat G, Olaniyan JO, Fylan B, et al. Res Social Adm Pharm. 2022;18:3534-3541.
The COVID-19 pandemic has impacted all aspects of healthcare delivery for both patients and health care workers. This study explored the how COVID-19-related policies and initiatives intended to improve patient safety impacted workflow, system adaptations, as well as organizational and individual resilience among community pharmacists.
O'Hara JK, Reynolds C, Moore S, et al. BMJ Qual Saf. 2018;27:673-682.
Patients' reports of safety concerns can reveal adverse events that would not be identified otherwise. In this cluster-randomized trial of patient engagement, patient volunteers read and classified incident reports submitted by hospitalized patients enrolled in the study. Following classification by patients, reports underwent a standardized, validated review by multiple researchers to determine if the event constituted a patient safety incident. Overall, about one-third of patient-reported concerns were deemed to be patient safety incidents. Medication safety issues were the most prevalent concerns. The authors conclude that patient reporting of safety events lends a unique and necessary perspective to error reporting. A previous PSNet perspective highlighted the advantages to and limitations of engaging patients in patient safety.
Fylan B, Armitage G, Naylor D, et al. BMJ Qual Saf. 2018;27:539-546.
Patient engagement can improve identification and prevention of medication errors. This qualitative study interviewed cardiology patients about their experiences managing medications after being discharged from hospitals in the United Kingdom. The authors described various types of patient engagement in medication management as sources of system resilience.
Sheard L, Marsh C, O'Hara JK, et al. BMJ Open. 2017;7:e014558.
This study evaluated the implementation of a patient safety intervention. Frontline staff engagement with the intervention was highly variable and the intervention was not implemented as intended across the study sites. These results underscore the challenge of translating patient safety research into practice.
Lawton R, O'Hara JK, Sheard L, et al. BMJ Qual Saf. 2017;26:622-631.
Although patient engagement is widely recommended as a patient safety strategy, its impact on patient outcomes is unclear. In this cluster randomized trial, hospital wards were designated either to receive usual hospital care or to engage patients in safety by providing a questionnaire and an opportunity to report their positive and negative safety experiences. Investigators compared a global measure of safety, which included pressure ulcers, venous thromboembolism, catheter-associated urinary tract infections, and falls, between wards that engaged patients through this intervention with those that did not. While the participating hospital wards were able to collect safety feedback from patients in a feasible and acceptable manner, researchers found no statistically significant differences in safety outcomes in the patient engagement wards and the usual care wards. The authors conclude that evidence is insufficient to recommend this questionnaire-based patient engagement strategy as a way to enhance safety.
O'Hara JK, Lawton R, Armitage G, et al. BMC Health Serv Res. 2016;16:676.
The role of patients in promoting their own safety remains controversial. Although some studies have shown that patients are able to identify errors not detected via other means, others have shown that patients may conflate service quality with safety issues. In this feasibility study, authors describe the development and testing of an intervention designed to collect feedback from hospitalized patients about the safety of their care.
Wright J, Lawton R, O’Hara J, et al. National Institute for Health Research; 2016:1-296.
Hospitals and health care providers are developing new ways to involve patients and families in safety efforts. This report discusses a National Health Service program designed to enhance feedback opportunities from consumers and assess these initiatives. Although the investigators found no direct care improvements associated with the interventions, the approaches they used to test patient engagement strategies (such as the ability to raise concerns) were successful.
O'Hara JK, Armitage G, Reynolds C, et al. BMJ Qual Saf. 2017;26:42-53.
Patients are increasingly encouraged to participate in preventing and reporting errors. This study evaluated three different methods for capturing safety concerns from patients: bedside interviews, a paper-based form, and a patient safety hotline. Face-to-face interviews generated more than twice as many concerns per patient compared with the other strategies.
Lawton R, O'Hara JK, Sheard L, et al. BMJ Qual Saf. 2015;24:369-76.
Patient engagement programs are being widely implemented as means of improving the safety and quality of hospital care, and prior studies have shown that patients can identify safety issues that go undetected by other methods. This study examined the relationship between patient and staff perception of safety and overall safety outcomes by comparing patient perceptions of safety (measured by the Patient Measure of Safety survey), staff perception of safety (measured by the AHRQ Hospital Survey on Patient Safety Culture), and quantitative measures of patient safety events (measured by the NHS Safety Thermometer). The investigators found that both Patient Measure of Safety and Hospital Survey of Patient Safety Culture results were correlated with objective measures of safety, and they appeared to contribute independently to predicting safety outcomes. This study provides further evidence for including patient perspectives in identifying and measuring safety issues.
Armitage G, Newell R, Wright J. J Eval Clin Pract. 2010;16:1189-97.
This analysis of voluntarily reported medication errors found that the reports often did not yield useful data. The authors make suggestions, based on error theory, to improve reporting systems to enhance the ease of reporting and the quality of error reports.
Sirriyeh R, Lawton R, Gardner P, et al. Qual Saf Health Care. 2010;19:e43.
Committing a medical error can have profound emotional effects on providers, to the point that clinicians have been termed the "second victim" of errors. This systematic review found that feelings of guilt, shame, and loss of confidence were widespread among clinicians after involvement in an error. However, few studies addressed coping strategies for affected professionals, and those that did generally described existing workplace support structures as inadequate. Some studies report that discussion of errors with colleagues is generally beneficial, and institutions have begun to implement innovative curricula and support systems to aid professionals who have been involved in an error.