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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 - 15 of 15 Results
Kieren MQ, Kelly MM, Garcia MA, et al. Acad Pediatr. 2023;Epub Jun 9.
Parents of children with medical complexity are an important part of the care team and can raise awareness of safety concerns. This study included parents of children with medical complexity who had reported safety concerns to members of their child's healthcare team. Parents whose concerns were validated and addressed felt increased trust in the team and hospital, whereas those whose concerns were invalidated or ignored felt disrespected and judged.
Mercer AN, Mauskar S, Baird JD, et al. Pediatrics. 2022;150:e2021055098.
Children with serious medical conditions are vulnerable to medical errors. This prospective study examined safety reporting behaviors among parents of children with medical complexity and hospital staff caring for these patients in one tertiary children’s hospital. Findings indicate that parents frequently identify medical errors or quality issues, despite not being routinely advised on how to report safety concerns.
Khan A, Baird JD, Kelly MM, et al. Pediatrics. 2022;149:e2021053913.
Patient and family engagement in safety efforts is supported in research but patients and clinicians still experience barriers in providing and accepting feedback. In this study, parents and caregivers of medically complex children reported uncertainty about whether and to whom to report concerns. Other themes included misalignment of staff and parent expectations of care and staff and leadership buy-in on the value of parent engagement.
Williams BW. Acad Med. 2019;94:1081-1083.
Root causes of failures can exist at the system, equipment, and individual level. This commentary explores how negative family experiences can affect physician responses to complex, stressful situations. The author suggests that education and awareness programs to address disrespectful physician behavior take childhood experiences into account.
Howard IL, Bowen JM, Shaikh LAHA, et al. Emerg Med J. 2017;34:391-397.
Trigger tools can identify patient results that may represent adverse events in an automated manner. This study determined potential triggers for adverse events in the emergency department setting. The final 8-item trigger tool identified through an iterative validation process had a sensitivity close to 80% and specificity around 60%, in line with trigger tools in other settings.
Williams BW, Flanders P. Australas Psychiatry. 2016;24:144-147.
This case series of physicians evaluated for fitness for duty found that health, independent of age, is related to worsening clinical performance. The authors recommend screening for physician fitness based on overall physical and mental health rather than at a given age threshold.
Bilimoria KY, Chung JW, Hedges L, et al. New Engl J Med. 2016;374:713-727.
Resident physician duty hour policies have generated rigorous debate, particularly following the most recent ACGME changes implemented in 2011, which shortened maximum shift lengths for interns and increased time off between shifts. This national study cluster-randomized 118 general surgery residency programs to adhere to current ACGME duty hour policies or to abide by more flexible rules that essentially followed the prior standard of a maximum 80-hour work week. Between these two groups, there were no significant differences in patient outcomes, including death and serious complications. Residents reported similar levels of satisfaction with their overall education quality and their well-being. An accompanying editorial notes that the study authors interpret these results as supporting flexible work-hour rules. Alternatively, the editorial author suggests that this study refutes concerns that the new policy compromises patient safety, and as such there is no compelling reason to backtrack on its implementation.
Sanfey H, Fromson J, Mellinger JD, et al. J Am Coll Surg. 2015;221:621-7.
Physician burnout has been linked to medical errors among surgeons. This national survey study of 212 surgeons identified differences in how male and female surgeons deal with seeking assistance when under stress. Men and women worked similar hours, but female surgeons were less satisfied with work–life balance and personal fulfillment. Male surgeons were more likely to seek support from colleagues or friends, whereas women tended to go to professional counselors.
Coverdill JE, Carbonell AM, Fryer J, et al. Acad Med. 2010;85:S72-5.
This survey of general surgery residents found that most are struggling with balancing duty hour requirements and responsibility for their patients. In particular, residents reported difficulty adhering to shift length restrictions, and little to no education on handoffs and signouts.
DesRoches CM, Rao SR, Fromson J, et al. JAMA. 2010;304:187-193.
Patient safety initiatives will increasingly balance the tension between systems change and individual accountability, and medical professionalism is often at the center of this discussion. Although certain behaviors in medical school predict unprofessional behavior, efforts to teach these skills have been described, particularly in addressing disruptive behavior. This study surveyed physicians and found that nearly 70% believe that it is their professional responsibility to report an impaired or incompetent colleague. However, of those with knowledge of such a colleague, 33% failed to report them to a relevant authority. Barriers to reporting included a belief that it wasn’t their responsibility, nothing would happen from reporting them, and fear of retribution. A related editorial discusses medical professionalism in the context of this study’s findings and weighs different strategies to address the challenges. A past AHRQ WebM&M conversation and commentary also discuss professionalism and patient safety.
Leape L, Fromson J. Ann Intern Med. 2006;144:107-15.
This commentary discusses the current systemwide limitations in measuring physician performance and how this deficiency compromises the ability to provide high-quality and safe patient care. The authors provide a background and contextual basis for definitions such as professional competence and disruptive behavior before examining the extent of the problem. They build on past efforts of measures to predict unprofessional or disruptive behavior and discuss a model and strategy for addressing physician performance nationally. The authors conclude with a call to action for organizations best positioned to lead this charge, including the American Board of Medical Specialties and the Joint Commission on Accreditation of Healthcare Organizations.