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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 43 Results
Kane J, Munn L, Kane SF, et al. J Gen Intern Med. 2023;Epub Sept 5.
Clinicians and staff are encouraged to speak up about safety concerns as a part of patient safety culture. This review had two aims: to review the literature on speaking up for patient safety, and to develop a single definition of "speaking up" in healthcare. 294 articles were identified with 51 directly focused on speaking up and the remaining on other aspects such as communication. 11 distinct definitions were identified from which the authors developed a single definition: a healthcare professional identifying a concern that might impact patient safety and using his or her voice to raise the concern to someone with the power to address it.
White VanGompel E, Carlock F, Singh L, et al. J Obstet Gynecol Neonatal Nurs. 2023;52:211-222.
Cesarean delivery can lead to increased maternal morbidity and mortality. In this repeated cross-sectional study, physicians, nurses, and midwives were surveyed about their attitudes towards elective induction of labor before and after results were published from a large, randomized trial (Randomized Trial of Induction Versus Expectant Management, or ARRIVE) supporting elective inductions at 39 weeks to reduce the likelihood of a cesarean. Findings indicate that physician attitudes about induction shifted in favor of induction after ARRIVE, whereas nurse attitudes did not change. Qualitative analyses revealed four themes regarding attitudes towards induction- the importance of timing, identifying who should receive inductions, the need for clear protocols and more staff, and improvements to the induction of labor processes. 
Grauer JS, Kana LA, Alzouhayli SJ, et al. Surgery. 2022;173:357-364.
Surgical fires, while rare, can result in the injury, permanent disability, or death of patients or healthcare workers. Between 2000 and 2020, 565 surgical fires resulting in injury were reported to the FDA’s Manufacturer and User Facility Device Experience (MAUDE) database. Fires were most likely to occur during upper aerodigestive tract and head and neck surgeries; these were also most likely to result in life-threatening injury.
Ito A, Sato K, Yumoto Y, et al. Nurs Open. 2021;9:467-489.
Ensuring that healthcare workers feel comfortable speaking up about concerns – also known as psychological safety – is an essential component of patient safety. This concept analysis identified five attributes of psychological safety in healthcare settings – (1) perceptions of consequences related to taking interpersonal risks; (2) strong interpersonal relationships; (3) group-level phenomenon; (4) safe work environments supporting interpersonal risks and (5) non-punitive culture.
Kane‐Gill SL, Wong A, Culley CM, et al. J Am Geriatr Soc. 2020;69:530-538.
Medication reconciliation and medication regimen reviews can reduce adverse drug events (ADEs) in older adults. This study assessed the impact of a pharmacist-led, patient-centered telemedicine program to manage high-risk medications during transitional and nursing home care. The program included telemedicine-based medication reconciliation at admission and medication regimen reviews throughout the nursing home stay, coupled with clinical decision support. Residents in the program experienced fewer adverse drug events compared to a usual care group. This innovative model has the potential to further reduce medication errors in nursing home residents.
Ward ME, De Brún A, Beirne D, et al. Int J Environ Res Public Health. 2018;15:E1182.
Change initiatives require broad-based collective design strategies to ensure the range of needs are addressed. This commentary explains how one hospital group used codesign methods to engage leadership in a teamwork and culture improvement project. The authors describe specific tools and tactics used to implement the work and summarize the value of the approach for other health care organizations.
Kane-Gill SL. Pharmacotherapy. 2018;38:782-784.
Articles in this special issue focus on adverse drug reactions and proactive strategies to reduce risks, such as using natural language processing to detect adverse effects related to medications, engaging community pharmacists in the medication process through better connectivity to patient data, and improving the evidence base on reducing smart pump nuisance alarms.
Buckley MS, Rasmussen JR, Bikin DS, et al. Ther Adv Drug Saf. 2018;9:207-217.
This retrospective study examined the performance of trigger alerts designed to predict drug-related hazardous conditions in both ICU and non-ICU patients. The authors conclude that the alerts were not effective in identifying drug-related hazardous conditions in either setting and suggest that poorly performing alerts may contribute to alert fatigue.
Kane JM, Colvin JD, Bartlett AH, et al. Pediatrics. 2018;141:e20173335.
Opioid-related harm is a widely recognized patient safety concern. This study retrospectively examined critical care unit hospitalizations for opioid ingestions among children between 2004 and 2015. Over this period, hospitalizations for opioid ingestion increased dramatically, and nearly half led to critical care unit admission. Although the mortality rate for pediatric opioid ingestion was 1.6%, more than one-third of cases required mechanical ventilation. The authors call for stronger efforts to address the impact of the opioid epidemic on children. A previous PSNet interview discussed factors that contributed to the increase in opioid-related harm and strategies to address this growing patient safety concern.
Kane-Gill SL, O'Connor MF, Rothschild JM, et al. Crit Care Med. 2017;45:1481-1488.
These paired systematic reviews examined alert fatigue in the intensive care unit. The first systematic review found several strategies to reduce alerts including prioritizing alerts, developing multipart rules instead of simple alerts, and customizing commercial platforms with end-user input. The second systematic review found that alarm best practices from high reliability industries are not adhered to in intensive care unit settings.
Kane RL, Huckfeldt P, Tappen R, et al. JAMA Intern Med. 2017;177:1257-1264.
Reducing acute care hospitalizations from nursing homes is a patient safety priority. This cluster-randomized controlled trial compared a multimodal quality improvement intervention at long-term care facilities and found no difference in the rate of acute care hospitalizations compared to usual nursing home care. These results emphasize the challenge of improving safety outcomes in real-world clinical settings.
Kane-Gill SL, Achanta A, Kellum JA, et al. World J Crit Care Med. 2016;5:204-211.
Medication administration technologies can help collect data to enhance processes and reduce medication errors. This commentary discusses how organizations are using clinical decision support systems to track problems and incorporating different data sets to prevent adverse drug events.
Geiger-Brown J, Rogers VE, Trinkoff AM, et al. Chronobiol Int. 2012;29.
Nurses' working conditions have been shown to affect patient safety. This study found that nurses working successive 12-hour shifts accrue significant sleep debt, regardless of whether these shifts occur in the daytime or at night. Further work should examine the effects of nurse fatigue on patient outcomes.
Coletti DJ, Stephanou H, Mazzola N, et al. J Eval Clin Pract. 2015;21:831-9.
This study found that primary care patients' reports of their current medications differed from electronic health record medication lists, as has been previously documented in post-hospital care. Patients with more medication discrepancies also reported poorer medication adherence, underscoring the importance of effective medication reconciliation in outpatient care.
DiPoto JP, Buckley MS, Kane-Gill SL. Drug Saf. 2015;38:311-7.
A persistent challenge in patient safety is detecting and intervening in unsafe situations before patients are harmed. Trigger tools have been widely used in retrospective studies to identify and characterize adverse events, and this study reports on a novel use for triggers—detecting potentially harmful drug interactions during the computerized provider order entry process. Trigger alerts in a computerized provider order entry system at three hospitals (academic, community, and rural) were reviewed by a pharmacist, who then either personally made changes or contacted the prescribing physician. The triggers were developed by a multidisciplinary team involving clinicians and information technologists and were tailored to identify clinically significant medication errors. The authors found that more than 40% of the alerts required pharmacist intervention, and that over 90% of pharmacist recommendations were accepted by the prescribing physicians. Therefore, the triggers used in this study generated far fewer false-positive alerts than seen in other studies. The proliferation of false-positive warnings is a primary contributor to alert fatigue, and although this study did not directly measure this phenomenon, it is plausible that use of more tailored alerts could avert alarm fatigue.