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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 39 Results

Kans J Med. 2023;June 2016:153-171.

The well-being of the healthcare workforce is known to impact care delivery. This article series draws from front-line scenarios to illustrate how a wide range or personal and professional challenges intersect to affect patient safety. Topics covered in the presented cases include work-life integration, gender discrimination and clinical mistakes.
Subbe CP, Hughes DA, Lewis S, et al. BMJ Open. 2023;13:e065819.
Failure to rescue refers to delayed or missed recognition of clinical deterioration, which can lead to patient complications and death. In this article, the authors used health economics methods to understand the health economic impacts associated with failure to rescue. The authors discuss the economic perspectives of various decision makers and how each group defines value. 
Crunden EA, Worsley PR, Coleman SB, et al. Int J Nurs Stud. 2022;135:104326.
Hospital-acquired pressure ulcers, categorized as a never event, are underreported, particularly when related to medical devices. Interviews with experts in hospital-acquired pressure ulcers revealed four domains related to reporting: 1) individual health professional factors, 2) professional interactions, 3) incentives and resources, and 4) capacity for organizational change. Teamwork, openness, and feedback were seen as the main facilitators to reporting, and financial consequences was a contributing barrier.
Uramatsu M, Maeda H, Mishima S, et al. J Cardiothorac Surg. 2022;17:182.
Wrong-patient transfusion errors can lead to serious patient harm. This case report describes a blood transfusion error and summarizes the systems issues that emerged during the root case analysis, as well as the corrective steps implemented by the hospital to prevent future transfusion errors. A previous Spotlight Case featured a near-miss transfusion error and strategies for ensuring safe transfusion practices.
Warm E, Ahmad Y, Kinnear B, et al. Acad Med. 2021;96:1268-1275.
Technical and procedural skills are an important emphasis of medical training. This article briefly summarizes the “as low as reasonably achievable” (ALARA) approach, which was developed for the nuclear industry and has been used in radiology. The authors outline how ALARA risk standards can be adapted by training program directors to measure procedural competency and assess and reduce bedside procedural risks.
Sanduende-Otero Y, Villalón-Coca J, Romero-García E, et al. Br J Anaesth. 2020;124:197-205.
Medication-related adverse events (MRE) occur frequently during anesthesia care and more research into preventing them is needed. This article presents a descriptive analysis of the MRE reported to the Spanish Anaesthesia Incident Reporting System database during the decade from 2008 through 2017. Of the 1970 MRE identified, the highest number (42%) occurred during the administration phase, and a greater percentage of administration-related MRE resulted in harm to patients (44% as opposed to 31% over all 1,970 events). The authors identified patterns and specific causes of MRE that they suggest could be mitigated using proven systems solutions.
van Gelderen SC, Zegers M, Robben PB, et al. BMC Health Serv Res. 2018;18:798.
Auditing for compliance with safety practices is performed frequently in the health care setting, both for learning and feedback as well as for regulatory purposes. In this survey study involving boards of directors and hospital leaders from 89 acute care hospitals in the Netherlands, researchers sought to identify factors for effective auditing and provide suggestions for how hospital boards can use such auditing practices to inform governance.
Dankbaar MEW, Richters O, Kalkman CJ, et al. BMC Med Educ. 2017;17:30.
This education study randomized medical students to learn about patient safety either through a text-based electronic module or a serious game activity with a didactic purpose. Students randomized to the game and the electronic module performed equally well on a patient safety knowledge assessment, and both groups performed better than students who did not have any patient safety education. Although students found the game more engaging, it also lasted about 3 hours compared to 1 hour for the text-based module.
van Dusseldorp L, de Waal GH-, Hamers H, et al. Jt Comm J Qual Patient Saf. 2016;42:545-554, AP1-AP3.
In health care, executive walk rounds are used to help senior leadership engage in discussions about safety issues with frontline staff. Although prior research has demonstrated a positive impact of walk rounds on safety culture in the hospital setting, less is known about their value in other types of care settings. In this mixed methods analysis, executive walk rounds were implemented across six long-term care institutions. Leaders reported that participating in walk rounds increased their awareness around safety issues and enhanced their engagement with frontline staff. An accompanying editorial discusses the utility of walk rounds in improving the safety culture in nursing homes.
Zegers M, Hesselink G, Geense W, et al. BMJ Open. 2016;6:e012555.
This review examined the evidence base for reducing adverse events in hospitals. Investigators found sufficient evidence to support implementation of certain types of interventions, such as rapid response teams to reduce cardiac arrest and mortality rates, bundles and checklists to mitigate hospital-acquired infections, and pharmacist interventions to decrease adverse drug events. However, the overall evidence base for many of the patient safety interventions used by hospitals is weak.
Hesselink G, Berben S, Beune T, et al. BMJ Open. 2016;6:e009837.
The growing focus on enhancing health care safety has placed new demands on hospital leadership to implement improvement initiatives. Examining governance of patient safety in the emergency department, this systematic review found that robust tools for monitoring patient safety and reporting errors are lacking.
Wassenaar A, van den Boogaard M, van der Hooft T, et al. J Clin Nurs. 2015;24:3233-44.
This qualitative study explored the means by which intensive care unit nurses enhance their patients' perception of safety. Nurses emphasized the importance of communicating with patients and families, ensuring patients' physical safety, and building trust with families so that patients feel safe.
van Sluisveld N, Hesselink G, van der Hoeven JG, et al. Intensive Care Med. 2015;41:589-604.
This systematic review revealed that limited evidence exists exploring handoffs from intensive care units to general wards, and most of the studies identified were of low quality. Two promising interventions include employing liaison nurses working across multiple settings and structured communication, which has been shown to improve handoffs. The authors advocate for these interventions to be tested widely in rigorous studies to determine their effectiveness.
Weenink JW, Westert GP, Schoonhoven L, et al. BMJ Qual Saf. 2015;24:56-64.
In this survey study, one-third of respondents reported an experience with an impaired or incompetent colleague within the last year. One limitation to the survey findings was the low 28% response rate, but the authors note that even if all non-respondents had no such encounters, the results suggest at least 9% of health care professionals have dealt with impaired or incompetent colleagues.
Griffiths P, Dall'Ora C, Simon M, et al. Med Care. 2014;52:975-981.
Although 12-hour nursing shifts are common in the United States, this study found that only 15% of European nurses worked 12 hours or more. Similar to prior research, longer nursing shifts were associated with lower quality of care and compromised patient safety. This study also found that nurses working extended shifts reported more care left undone. Nurses who worked overtime, even if shift length was less than 10 hours, described similar concerns. The authors warn that policies to adopt standard 12-hour nursing shifts as a cost-effective way of maintaining nurse–patient ratios may contribute to burnout. A past AHRQ WebM&M interview with Barbara Blakeney discussed the importance of proper nursing staffing for patient safety, and a prior AHRQ WebM&M commentary examines the complexities around balancing nurse staffing and workload.
Huis A, Schoonhoven L, Grol R, et al. Int J Nurs Stud. 2013;50:464-74.
In this cluster randomized trial, a strategy that sought to improve nurses' hand hygiene by emphasizing team commitment and leadership engagement did achieve higher hand hygiene rates compared with a standard quality improvement approach. However, the overall rate of hand hygiene adherence remained poor in both groups.
Hesselink G, Vernooij-Dassen M, Pijnenborg L, et al. Med Care. 2013;51:90-8.
Focus groups of patients, hospital physicians, outpatient physicians, and nurses revealed many aspects of organizational culture that impede progress in enhancing care transitions. A recent systematic review identified promising strategies for improving continuity of care at discharge.
van Rensen ELJ, Groen EST, Numan SC, et al. Anesth Analg. 2012;115:1183-7.
This analysis of videotaped postoperative patient handoffs revealed that the majority of clinicians engaged in multitasking—handover of both equipment and clinical information—while transferring care. Such behavior violates the sterile cockpit concept and may be a source of error during handoffs.
Göbel B, Zwart DLM, Hesselink G, et al. BMJ Qual Saf. 2012;21 Suppl 1:i106-13.
Although seminal studies have documented persistent problems in care transitions, including readmissions and adverse events after discharge, understanding of the basic mechanisms of these problems remains incomplete. This Dutch study examines the hospital discharge process through a clinical microsystems approach, using detailed interviews with patients, nurses, hospital physicians, and primary care physicians to construct a 360-degree view of the factors contributing to effective and ineffective transitions. The major theme that emerged was a lack of consistent information transfer across settings, implying the need for both technological solutions and increased personal contact between hospital-based and outpatient clinicians. This study is part of a special theme issue of BMJ Quality and Safety dedicated to the issue of care transitions.