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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 74 Results
Paull DE, Newton RC, Tess AV, et al. J Patient Saf. 2023;19:484-492.
Previous research suggests that residents may underutilize adverse event reporting tools. This article describes an 18-month clinical learning collaborative among 16 sites intended to increase resident and fellow participation in patient safety event investigations. Researchers found the collaborative increased participation in event investigation and improved the quality of the investigation.

Peard LM, Teplitsky S, Annabathula A, et al. Can J Urol. 2023;30(2):11467-11472.

Root cause analysis (RCA) is one tool commonly used to identify factors contributing to adverse events. Using RCA data from the Veterans Health Administration (VHA), this study characterized adverse events occurring during urologic procedures. The most common causes of adverse events were improperly functioning equipment (e.g., broken scopes or smoking light cords), wrong site surgeries, and retained surgical items.
Riblet NB, Soncrant C, Mills PD, et al. Mil Med. 2023;188:e3173-e3181.
Patient suicide is a sentinel event, and suicide among veterans has gained attention. In this retrospective analysis of suicide-related events reported to the Veterans Health Administration (VHA) National Center for Patient Safety between January 2018 and June 2022, researchers found that deficiencies in mental health treatment, communication challenges, and unsafe environments were the most common contributors to suicide-related events.
Yackel EE, Knowles RS, Jones CM, et al. J Patient Saf. 2023;19:340-345.
The COVID-19 pandemic dramatically changed healthcare delivery and exacerbated threats to patient safety. Using Veterans Health Administration (VHA) National Center for Patient Safety data, this retrospective study characterized patient safety events related to COVID-19 occurring between March 2020 and February 2021. Delays in care and exposure to COVID-19 were the most common events and confusion over procedures, missed care, and failure to identify COVID-positive patients before exposures were the most common contributing factors.
Mills PD, Louis RP, Yackel E. J Healthc Qual. 2023;45:242-253.
Changes in healthcare delivery due to the COVID-19 pandemic resulted in delays in care that can lead to patient harm. In this study using patient safety event data submitted to the VHA National Center of Patient Safety, researchers identified healthcare delays involving laboratory results, treatment and interventional procedures, and diagnosis.   
Charles MA, Yackel EE, Mills PD, et al. J Patient Saf. 2022;18:686-691.
The first surge of the COVID-19 pandemic forced healthcare organizations to respond to patient safety issues in real-time. The Veterans Health Administration’s National Center for Patient Safety established two working groups to rapidly monitor quality and safety issues and make timely recommendations to staff. The formation, activities, and primary themes of safety issues are described.
Appelbaum NP, Santen SA, Perera RA, et al. J Patient Saf. 2022;18:370-375.
Residents and trainees frequently report experiencing bullying and disrespectful behaviors in the workplace. This study explored the relationship between resident psychological safety, perceived organizational support, and humiliation. Results indicate resident perception of increased organizational support (e.g., help is available when they have a problem) reduces the negative impact of humiliation on their psychological safety.
Politi RE, Mills PD, Zubkoff L, et al. J Patient Saf. 2022;18:e1061-e1066.
Delays in diagnosis and treatment can lead to poor outcomes for patients. Researchers reviewed root cause analysis (RCA) reports to identify factors contributing to delays in diagnosis and treatment among surgical patients at the Veterans Health Administration. Of the 163 RCAs identified, 73% reflected delays in treatment, 15% reflected delays in diagnosis, and 12% reflected delays in surgery. Policies and processes (e.g., lack of standardized processes, procedures not followed correctly) was the largest contributing factor, followed by communication challenges, and equipment or supply issues.
Walton E, Charles M, Morrish W, et al. J Patient Saf. 2022;18:e620-e625.
J Patient Saf … Dialysis is a common procedure that carries … and (4) the method for hemodialysis delivery. … Walton E,  Charles M, Morrish W, et al. Hemodialysis bleeding events and deaths: …
Norris B, Soncrant C, Mills PD, et al. Jt Comm J Qual Patient Saf. 2021;47:489-495.
Opioid misuse and overdose continues to be a patient safety concern. This study conducted root cause analyses of 82 adverse event reports involving opioid use at the Veterans Health Administration. The most frequent event type was medication administration error and the most frequent root cause was staff not following hospital policies or hospitals not having opioid-related policies. 
Kulju S, Morrish W, King LA, et al. J Patient Saf. 2022;18:e290-e296.
Patient misidentification can lead to serious patient safety risks. Researchers used patient safety reports and root cause analyses (RCA) to characterize patient misidentification events in the Veterans Health Administration (VHA). The incidence of patient misidentification in inpatient and outpatient settings was similar and most commonly attributed to the absence of two unique patient identifiers. The authors identified three strategies to mitigate misidentification based on high-reliability principles: (1) develop policies for patient identification throughout the continuum of care, (2) develop policies to report and monitor patient misidentification measures, and (3) apply quality and process improvement tools to patient identification emphasizing use by front line staff.  
Mills PD, Soncrant C, Gunnar W. BMJ Qual Saf. 2021;30:567-576.
This retrospective analysis used root cause analysis reports of suicide events in VA hospitals to characterize suicide attempts and deaths and provide prevention recommendations. Recommendations include avoidance of environmental hazards, medication monitoring, control of firearms, and close observation.
Gunnar W, Soncrant C, Lynn MM, et al. J Patient Saf. 2020;16:255-258.
Retained surgical items (RSI) are considered ‘never events’ but continue to occur. In this study, researchers compared the RSI rate in Veterans Health (VA) surgery programs with (n=46) and without (n=91) surgical count technology and analyzed the resulting root cause analyses (RCA) for these events. The RSI rate was significantly higher in for the programs with surgical count technology compared to the programs without (1/18,221 vs. 1/30,593). Analysis of RCAs found the majority of incidents (64%) involved human factors issues (e.g., staffing changes during shifts, staff fatigue), policy/procedure failures (e.g., failure to perform methodical wound sweep) or communication errors.
Gill S, Mills PD, Watts BV, et al. J Patient Saf. 2021;17:e898-e903.
J Patient Saf … This retrospective cohort study used root … (11%) or lacking standardization (10%). … Gill S, Mills PD, Watts BV, et al. A review of adverse event reports … departments in the Veterans Health Administration. J Patient Saf. 2020. Epub 2020 Feb 23. doi: …