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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 77 Results

Anaesth Intensive Care. 2023;51(6):372-421.

Centralized de-identified reports of patient safety events serve a core purpose for learning and improvement. This article collection contains research drawn from the Australian/New Zealand webAIRS database. Data reviewed include cesarean and pediatric regional anesthesia incidents submitted to webAIRS over a 13-year period.
Bauer ME, Albright C, Prabhu M, et al. Obstet Gynecol. 2023;142:481-492.
Reducing maternal morbidity and mortality is a critical patient safety priority. Developed by the Alliance for Innovation on Maternal Health (AIM), this patient safety bundle provides guidance for healthcare teams to improve the prevention, recognition, and treatment of infections and sepsis among pregnant and postpartum patients.
Baartmans MC, van Schoten SM, Smit BJ, et al. J Patient Saf. 2023;19:158-165.
Sentinel events are adverse events that result in death or severe patient harm and require a full organizational investigation to identify root causes and make recommendations to prevent recurrence. This study pooled sentinel event reports from 28 Dutch hospitals to identify common system-level contributing factors. Aggregation of system-level factors may provide more urgency in implementing recommendations than a single case at one organization.
Bloomer A, Wally M, Bailey G, et al. Geriatr Orthop Surg Rehabil. 2022;13:215145932211256.
Opioid use by older adults increases the risk of falls. This study examined electronic health record data to determine the proportion of older adults presenting to the emergency room or urgent care due to a fall who receive an opioid prescription, particularly those with at least one risk factor for misuse. Nearly one third of patients received a prescription for an opioid and/or benzodiazepine, and 11% had at least one risk factor for misuse.
Rosen A, Carter D, Applebaum JR, et al. J Patient Saf. 2022;18:e1219-e1225.
The COVID-19 pandemic had wide-ranging impacts on care delivery and patient safety. This study examined the relationship between critical care clinician experiences related to patient safety during the pandemic and COVID-19 caseloads during the pandemic. Findings suggest that as COVID-19 caseloads increased, clinicians were more likely to perceive care as less safe.
Levkovich BJ, Orosz J, Bingham G, et al. BMJ Qual Saf. 2023;32:214-224.
Rapid response teams, also known as medical emergency teams (MET), are activated when a patient demonstrates signs of clinical deterioration to prevent transfer to intensive care, cardiac arrest, and death. MET activations were prospectively reviewed at two Australian hospitals to determine the proportion of activations due to medication-related harms and assess the preventability of the activation. 23% of MET activations were medication-related, and 63% of those were considered preventable. Most preventable activations were patients with hypertension, and prevention strategies should focus on these patients.
Alpert AB, Mehringer JE, Orta SJ, et al. J Gen Intern Med. 2023;38:970-977.
Transgender patients who experience or perceive bias when receiving care may avoid or delay seeking care in the future. In this study, transgender patients reported on their experiences in viewing their electronic health record (EHR). In line with previous studies, transgender patients reported experiencing harms in several ways, such as providers using the wrong pronouns, wrong name, or wrong gender marker. The structure of the EHR (e.g., no separate fields for sex and gender) itself also created barriers to quality care.
Jun J, Ojemeni MM, Kalamani R, et al. Int J Nurs Stud. 2021;119:103933.
… Int J Nurs Stud … Burnout among nurses can compromise safe … inversely associated with outcome measures. … Jun J, Ojemeni MM, Kalamani R, et al. Relationship between nurse … and organizational outcomes: systematic review. Int J Nurs Stud. 2021;119:103933. doi: 10.1016/j.ijnurstu.2021.103933. …
Chong LSH, Kerklaan J, Clarke S, et al. JAMA Pediatr. 2021;61:396-405.
Transgender and nonbinary individuals may delay or avoid seeking necessary healthcare due to fears of discrimination. This systematic review of qualitative studies of the perspectives of transgender youths identified six major themes regarding their experiences with accessing healthcare, including fear, vulnerability, and systemic barriers. The authors recommend several strategies to improve access to healthcare for transgender individuals.
WebM&M Case April 28, 2021
… start by defining terms. Packing refers to any material (e.g., ribbon or rolled gauze, cotton wadding, lap pads, … vaginal packing. AORN Journal, 2020; 111(3). Gibbs, Verna C. NoThing Left Behind®: The Prevention of Retained Surgical … doi:10.1097/NNA.0b013e3181c47cd6. Hjörleifsson S, Bjorvatn B, Meland E, et al. The when and how of the gynaecological …
Sprogis SK, Street M, Currey J, et al. Aust Crit Care. 2021;34:580-586.
Medical emergency teams (MET), also known as rapid response teams, are used to improve the identification and management of patients demonstrating signs of rapid deterioration. This study found that modifying activation criteria to trigger METs at more extreme levels of clinical deterioration were not associated with negative patient safety outcomes.
Self WH, Tenforde MW, Stubblefield WB, et al. MMWR Morb Mortal Wkly Rep. 2020;69:1221-1226.
This study examined the prevalence and risk factors for COVID-19 infection among frontline healthcare personnel who work with COVID-19 patients. Serum specimens were collected from a convenience sample of 3,248 frontline personnel between April 3 and June 19, 2020.  Six percent (6%) tested positive for SARS-CoV-2 antibodies; a high proportion of these individuals did not suspect that they had been previously infected. This study highlights the role that asymptomatic COVID-19 infections play and authors suggest that enhanced screening and universal use of face coverings in hospitals are two strategies to reduce COVID-19 transmissions in healthcare settings.
Reaume M, Farishta M, Costello JA, et al. Postgrad Med J. 2020;97:55-58.
Point-of-care ultrasounds (POCUS) are considered a powerful tool to enhance patient safety through expedited diagnosis, but also present safety threats. There is a concern that POCUS use may contribute to diagnostic error lawsuits. The authors reviewed lawsuits involving the diagnostic use of POCUS in internal medicine, pediatrics, family medicine, and critical care and did not find any cases of physicians in these specialties being subject to adverse legal action for the diagnostic use of POCUS.   
Choi GYS, Wan WTP, Chan AKM, et al. Br J Anaesth. 2020;125:e236-e239.
This study used high-fidelity clinical simulation to replicate admission, including tracheal intubation, of a patient with suspected or known COVID-19 infection to assess the ability of healthcare teams to effectively use personal protective equipment (PPE), the use of intubation protocols and infection control guidelines. Based on observations of 11 simulations involving 44 participants, several infection control-related workflow problems and safety threats were identified, including issues with PPE donning and doffing, advance preparation of intubation and ventilation strategies, environmental protection measures, communication difficulties, and accessibility of key drugs and equipment. These findings resulted in guideline changes, modifications to the environment and implementation of workflow modifications to improve ability of staff to adhere to infection control guidelines.
Wasserman JA, Redinger M, Gibb T. New England Journal of Medicine. 2020;382.
This paper discusses adapting a just culture framework to respond to unprofessional behavior in medical trainees. Such an adaptation can distinguish among different kinds of lapses (medical error, lapse in professionalism), set clear expectations for behavior, promotes fairness in the evaluation process and encourages consistency in the response to the behavior. Applying a ‘just culture’ framework can help medical educators facilitate learning while fairly and rigorously addressing problematic behaviors.
Leamy K, Thompson J, Mitra B. Australas Emerg Care. 2019;22:221-226.
This article reports the results of a prospective pre-post interventional study undertaken to determine whether providing a simplified information card to patients (in addition to discharge summaries) upon discharge from Australian emergency departments would improve patient awareness of their diagnosis and follow-up requirements. Brief interviews conducted with 112 pre-intervention study participants and 117 who received the short discharge card, indicated statistically significant improvement (73.2% to 89.7%, p<0.001) in patient awareness with the short discharge card. 
Trent M, Dooley DG, Dougé J, et al. Pediatrics. 2019;144:e20191765.
Children and adolescents are particularly vulnerable to systemic weaknesses in health care. This guidance examines the impact of racism and implicit biases on pediatric patients. The policy summarizes the evidence on institutionalized racism and health to motivate the adoption of strategies to reduce that impact at the system and organizational level.