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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 20 Results
Zhong J, Simpson KR, Spetz J, et al. J Patient Saf. 2023;19:166-172.
Missed nursing care is a key indicator of patient safety and has been linked to safety climate. Survey responses from 3,429 labor and delivery nurses from 253 hospitals across the United States found an average of 11 of 25 aspects of essential nursing care were occasionally, frequently, or always missed. Higher perceived safety climate was associated with less missed care. The authors discuss the importance of strategies to reduce missed care, such as adequate nurse staffing, ensuring nonpunitive responses to errors, and promoting open communication.
Lyndon A, Davis D-A, Sharma AE, et al. BMJ Qual Saf. 2023;32:369-372.
Patient perspectives can provide unique insights into care quality. This commentary examines how ascertaining whether patients ‘feel safe’ results in their ‘being safe’ is an ineffective goal in patient safety. The authors argue that patient experiences degrading humanity be considered never events and suggest feelings as important considerations for patient engagement and health care improvement.
Lyndon A, Simpson KR, Spetz J, et al. Appl Nurs Res. 2022;63:151516.
Missed nursing care appears to be associated with higher rates of adverse events. More than 3,600 registered nurses (RNs) were surveyed about missed care during labor and birth in the United States. Three aspects of nursing care were reported missing by respondents: thorough review of prenatal records, missed timely documentation of maternal-fetal assessments, and failure to monitor input and output.
Perspective on Safety December 22, 2018
… consequences. The rate of severe maternal morbidity (e.g., massive blood transfusion, eclampsia, hysterectomy, heart … relationships, and effective communication. … AudreyLyndonAudrey Lyndon
This perspective examines the troubling decline in maternal health outcomes in the United States and summarizes recent national initiatives to improve safety in maternity care.
Lyndon A, Malana J, Hedli LC, et al. J Obstet Gynecol Neonatal Nurs. 2018;47:324-332.
A vital component of engaging patients in safety is eliciting their perspective on how they experience both routine care and adverse events. Researchers interviewed women who gave birth in hospitals about what contributed to their sense of safety. Participants emphasized clear communication and empathy as strategies to avoid psychological harm.
Bardach N, Lyndon A, Asteria-Peñaloza R, et al. BMJ Qual Saf. 2016;25:889-897.
Patients' experiences with safety issues influence their perceptions of hospital quality. This study examined online reviews of hospitals and found concerns discussed in narratives that would not have surfaced using the Hospital Consumer Assessment of Healthcare Providers and Services patient satisfaction instrument. A significant proportion of narrative reviews raised concern about safety and trust.
WebM&M Case October 1, 2016
A pregnant woman was admitted for induction of labor for postterm dates. Prior to artificial rupture of membranes (AROM), the intern found a negative culture for group B strep in the hospital record but failed to note a positive culture in faxed records from an outside clinic. Another physician caught the error, ordered antibiotics, and delayed AROM to allow time for the medication to infuse.
Simpson KR, Lyndon A, Davidson LA. Nurs Womens Health. 2016;20:358-66.
Labor and delivery care is considered high risk for sentinel events should something go wrong. This review discusses how audible surveillance in this setting can contribute to alert fatigue and distraction among nurses and raises concerns that no standards exist to improve the effectiveness of electronic fetal monitoring.
Perspective on Safety January 1, 2016
… to broader problems outside of their control (e.g., equipment design or medication labeling). Source: … based on accumulated experience and data. … Kiran … Audrey … Gupta … Lyndon … Kiran Gupta … Audrey Lyndon
Root cause analysis is widely accepted as a key component of patient safety programs. In 2016, the literature outlined ongoing problems with the root cause analysis process and shed light on opportunities to improve its application in health care. This Annual Perspective reviews concerns about the root cause analysis process and highlights recommendations for improvement put forth by the National Patient Safety Foundation.
Lyndon A, Johnson C, Bingham D, et al. Obstet Gynecol. 2015;125:1049-55.
Poor communication among perinatal health care teams has been highlighted as a safety concern. Exploring human factors, leadership behaviors, and root causes that may contribute to miscommunication, this commentary recommends ways individual clinicians, team leaders, managers, organizations, and patients and their families can enhance safety in the labor and delivery setting.
Perspective on Safety January 1, 2015
… on clinician physical and psychological health. … AudreyLyndonAudrey Lyndon
Clinician burnout is prevalent across health care settings and may impair clinicians' ability to maintain safe practices and detect emerging safety threats. This Annual Perspective summarizes studies published in 2015, with a particular focus on the relationship between burnout and patient safety, and interventions to address burnout among clinicians.
Lyndon A, Jacobson CH, Fagan KM, et al. BMJ Qual Saf. 2014;23:902-9.
This interview, observation, and survey study found that parents of infants in neonatal intensive care units identified three core aspects of safety: physical safety relating to immediate treatment, the effect of care on future development, and emotional safety for infants and family, such as having confidence in caregivers. These results argue for enhancing patient and family engagement in safety in this setting.
WebM&M Case May 1, 2014
In the preoperative area, a man scheduled for excision of a groin lipoma received regional anesthesia (right iliac block) and was taken to the operating room. There, without alerting anyone, the patient attempted to rise to use the restroom, but—because his leg was numb—fell and hit his head. He reported acute neck pain and was transferred to the local emergency department.
Maxfield DG, Lyndon A, Kennedy HP, et al. Am J Obstet Gynecol. 2013;209.
Safety culture in labor and delivery wards appears to be suboptimal based on this survey, which found that nearly all physician, nurse, and midwife respondents had witnessed an unsafe patient situation within the past year. However, few respondents had shared their concerns with other staff either formally or informally.