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Patient Safety Network

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 117 Results
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    • Vital signs: maternity care experiences — United States, April 2023.
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    • Mohamoud YA, Cassidy E, Fuchs E, et al. MMWR Morb Mortal Wkly Rep. 2023;72:961–967.
    Previous research has found that women often experience mistreatment and discrimination during maternity care. This CDC analysis of survey data for 2,402 respondents found that approximately one in five women experienced at least one type of mistreatment during maternity care (i.e., being ignored or refused, being shouted at or scolded, having their physical privacy violated). Nearly 29% of respondents reported experiencing at least one form of discrimination during their maternity care (i.e., age-, weight-, income-, or race/ethnicity-based discrimination).
    Final Report on Prioritization of Patient Safety Practices for a New Rapid Review or Rapid Response. Making Healthcare Safer IV Series.
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    • Rosen M, Dy SM, Stewart CM, et al. Making Healthcare Safer IV Series.  Rockville, MD: Agency for Healthcare Research and Quality; July 2023. AHRQ Publication no. 23-EHC019-1.

    Reducing preventable harm in healthcare settings remains a national priority. This report summarizes the results of the prioritization process used to identify patient safety practices meriting inclusion in the fourth installment of the Making Healthcare Safer (MHS) series (previous installments were published in 2001, 2013, and 2020). The fifteen-member Technical Expert Panel identified 27 priority patient safety practices for examination in the forthcoming report, including several practices that have not been covered in previous MHS reports (e.g., family/caregiver engagement, preventing non-ventilator associated pneumonia, supply chain disruption, high reliability, post-event communication programs).
    Fatigue amongst anaesthesiology and intensive care trainees in Europe: a matter of concern.
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    • Abramovich I, Matias B, Norte G, et al. Eur J Anaesthesiol. 2023;40:587-595.
    Fatigue and sleep deprivation of anesthesia providers can result in decreased non-technical skills and psychomotor functioning. This study of 1,200 anesthesia and intensive care trainees in Europe describes the impact of work-related fatigue on well-being, commuting, and potential for medical errors. Two-thirds of respondents reported making or nearly making a medical error after working long hours. In addition to implementing shorter work schedules, the authors also encourage a culture where it is acceptable to admit fatigue, and where resting is encouraged.
    Physician and nurse well-being and preferred interventions to address burnout in hospital practice: factors associated with turnover, outcomes, and patient safety.
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    • Aiken LH, Lasater KB, Sloane DM, et al. JAMA Health Forum. 2023;4:e231809.
    While the association between clinician burnout and patient safety are not new, the COVID-19 pandemic brought this safety concern back to the forefront. In this study conducted at 60 US Magnet hospitals, nurses and physicians reported high levels of burnout and rated their hospital unfavorably on patient safety. Increased nurse staffing was the top recommendation to reduce burnout with less emphasis on wellness and resilience programs.
    Development of the Leapfrog Group's bar code medication administration standard to address hospital inpatient medication safety.
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    • Austin JM, Bane A, Gooder V, et al. J Patient Saf. 2022;18:526-530.
    Use of bar code medication administration (BCMA) technology in hospitals has been shown to decrease medication errors at the time of administration. In 2016, the Leapfrog Group implemented a standard for BCMA use as part of its hospital survey. This article describes the development, testing, and subsequent refinement of the BCMA standard.
    Influence of a general practice pharmacist on medication management for patients at risk of medicine-related harm: a qualitative evaluation.
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    • Jordan M, Young-Whitford M, Mullan J, et al. Aust J Gen Pract. 2022;51:521-528.
    Interventions such as deprescribing, pharmacist involvement, and medication reconciliation are used to reduce polypharmacy and use of high-risk medications such as opioids. In this study, a pharmacist was embedded in general practice to support medication management of high-risk patients. This study presents perspectives of the pharmacists, general practitioners, practice personnel, patients, and carers who participated in the program.
    Reducing pediatric emergency department prescription errors.
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    • Devarajan V, Nadeau NL, Creedon JK, et al. Pediatrics. 2022;149:e2020014696.
    Several factors contribute to the increased risk of prescribing errors for children, including weight-based dosing and drug formulation. This quality improvement project in one pediatric emergency department identified four key drivers and implemented four interventions to reduce errors. Prescribing errors were reduced across three plan-do-study-act cycles, and improvements were maintained six months after the final cycle.
    Error reduction in trauma care: lessons from an anonymized, national, multicenter mortality reporting system.
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    • Hamad DM, Mandell SP, Stewart RM, et al. J Trauma Acute Care Surg. 2022;92:473-480.
    By analyzing errors that lead to preventable or potentially preventable deaths in trauma care, healthcare organizations can develop mitigation strategies to prevent those errors from reoccurring. This study classified events anonymously reported by trauma centers using the Joint Commission on Accreditation of Healthcare Organizations Patient Safety Event Taxonomy. Mitigation strategies were most often low-level, person-focused (e.g., education and training).
    Inattentional blindness in anesthesiology: a gorilla is worth one thousand words.
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    • De Cassai A, Negro S, Geraldini F, et al. PLoS One. 2021;16:e0257508.
    Inattentional blindness occurs when individuals miss an unexpected event due to competing attentional tasks.  This study asked anesthesiologists to review the anesthetic management of five simulated cases, one of which included the image of a gorilla in the radiograph, to evaluate inattentional blindness. Only 4.9% of social media respondents reported an abnormality, suggesting that inattentional blindness may be common; the authors suggest several strategies to reduce this error.
    Experiences of transgender and gender nonbinary patients in the emergency department and recommendations for health care policy, education, and practice.
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    • Allison MK, Marshall SA, Stewart G, et al. J Emerg Med. 2021;61:396-405.
    Transgender and gender nonbinary (trans/NB) people can face discriminatory behaviors when accessing health care services. Trans/NB patients were interviewed about their experiences accessing care in emergency departments. Four themes were uncovered: 1) system and structural issues; 2) interactions with clinicians/staff; 3) perceptions of clinician knowledge and education; and 4) impact on future health and healthcare access. Recommendations for improvement were provided at the system and clinician level.
    Detecting and assessing suicide ideation during the COVID-19 pandemic.
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    • Simon GE, Stewart CC, Gary MC, et al. Jt Comm J Qual Patient Saf. 2021;47:452-457.
    … Jt Comm J Qual Patient Saf … The COVID-19 pandemic expanded the use … patients receiving virtual mental health care. … Simon GE, Stewart CC, Gary MC, et al. Improvement brief: detecting and … suicide ideation during the COVID-19 pandemic. Jt Comm J Qual Patient Saf. Epub 2021 Apr 22. …
    Drug-drug interactions and prescription appropriateness at hospital discharge: experience with COVID-19 patients.
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    • Cattaneo D, Pasina L, Maggioni AP, et al. Drugs Aging. 2021;38:341-346.
    Older adults are at increased risk of hospitalization due to COVID-19 infections. This study examined the potential severe drug-drug interactions (DDI) among hospitalized older adults taking two or more medications at admission and discharge. There was a significant increase in prescription of proton pump inhibitors and heparins from admission to discharge. Clinical decision support systems should be used to assess potential DDI with particular attention paid to the risk of bleeding complications linked to heparin-based DDIs.
    Assessment of physician sleep and wellness, burnout, and clinically significant medical errors.
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    • Trockel MT, Menon NK, Rowe SG, et al. JAMA Netw Open. 2020;3:e2028111.
    Fatigue among health care workers can increase the risk of errors. This large cross-sectional study of attending and house staff physicians found that sleep-related impairment was associated with increased burnout, decreased professional fulfillment, and increased self-reported clinically significant medical error. Organizational policies should focus on reducing sleep-related impairment in order to reduce harm to patients and physicians.
    Omissions of care in nursing homes: a uniform definition for research and quality improvement.
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    • Mangrum R, Stewart MD, Gifford DR, et al. J Am Med Dir Assoc. 2020;21:1587-1591.e2.
    Building upon earlier work, the authors engaged a technical expert panel to reach consensus on a definition for omissions of care in nursing homes. The article details the terms and concepts included in (and excluded from) the proposed definition, provides examples of omissions of care, intended uses (e.g., to guide quality improvement activities or training and education), and describes the implications of the definition for clinical practice, policy, and research.  
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