Skip to main content

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.

Search All Content

Search Tips
Filter By Author(s)
Advanced Filtering Mode
Date Ranges
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Additional Filters
Displaying 1 - 20 of 31 Results
Pring ET, Malietzis G, Kendall SWH, et al. Int J Surg. 2021;91:105987.
This literature review summarizes approaches to crisis management used by non-healthcare institutions (e.g., private businesses, large military organizations) in response to the COVID-19 pandemic and how healthcare organizations – particularly the surgical community – can leverage these approaches in operational planning and crisis management.
Pannick S, Archer S, Johnston MJ, et al. BMJ Open. 2017;7:e014401.
… sought to harness this expertise and perspective through a multifaceted intervention that involved structured … found that the prospective safety intervention created a sense of psychological safety in which team members were … with better insights into issues affecting care delivery. A past PSNet perspective discussed workarounds and resiliency …
Hull L, Athanasiou T, Russ S. Ann Surg. 2017;265:1104-1112.
Implementation science is utilized to understand how to apply research into practice. This review explores the use of implementation science in surgical patient safety initiatives to enable the translation of research into active care. The authors focus their discussion on the widely implemented World Health Organization surgical checklist to identify factors that drive and sustain improvement, including context, implementation strategies, and outcomes.
Howell A-M, Burns EM, Bouras G, et al. PLoS One. 2015;10:e0144107.
Measuring patient safety for individual hospitals and health systems remains a challenge. Incident reports provide one lens into patient safety, despite concerns about under-reporting. Numerous incident reports may indicate either a high number of errors or a robust safety culture that encourages blame-free event reporting. Therefore, it is unclear whether the volume of incident reports should serve as a patient safety metric. In this study, investigators analyzed all incident reports from the national reporting system in the United Kingdom and determined that hospitals with fewer litigation claims had more incident reports. They found no association between mortality or patient satisfaction and number of reports, and more incident reporting took place where survey results indicated a positive safety culture. These findings suggest that having a high quantity of incident reports does not signify an error-prone environment, and the authors recommend against using incident reporting rates as a quality metric. A past PSNet perspective discussed incident reporting systems as tools for improving patient safety.
Weigl M, Müller A, Holland S, et al. BMJ Qual Saf. 2016;25:499-508.
… & safety … BMJ Qual Saf … Workflow interruptions are often a necessary reality in busy clinical settings, but they can … risks for patient safety. This mixed-method study in a medium-sized community emergency department (ED) found that … for the consequences of interruptions. A prior AHRQ WebM&M perspective discussed interruptions and distractions in …
Mayer EK, Sevdalis N, Rout S, et al. Ann Surg. 2016;263:58-63.
… was effective only when it was fully completed—the odds of a postoperative complication were reduced by more than 40% if … results of this and other studies clearly demonstrate that a checklist is a complex intervention that requires rigorous implementation …
Anderson O, Brodie A, Vincent CA, et al. Ann Surg. 2012;255:1086-92.
This study reports on a failure mode and effect analysis used to detect and prioritize potential patient safety threats for surgical patients. Patients were directly involved in determining the severity of each potential hazard, providing a novel example of how patients may be engaged in safety efforts.