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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 - 16 of 16 Results
Weenink J-W, Tresfon J, van de Voort I, et al. BMC Health Serv Res. 2023;23:1048.
Promoting resilience across and within healthcare organizations is a key component of Safety-II. This qualitative study involving six teams across three hospitals in the Netherlands found that healthcare professionals, managers, and quality advisors hold differing perspectives regarding the right approach to clinical practices and the importance of certain clinical actions. The authors underscore the importance of team reflections to foster resilience and accountability across all levels within healthcare organizations.
Hogerwaard M, Stolk M, Dijk L van, et al. BMJ Open Qual. 2023;12:e002023.
Barcode medication administration (BCMA) technology is a useful tool to reduce medication administration errors (MAE) in the operating room. This study used a pre-post design to estimate the rate of MAE before and after BCMA implementation on infusion pumps. MAE were significantly reduced and up to 90% of errors were considered preventable, if the staff had utilized BCMA. Reasons for not using BCMA included unreadable barcodes, lack of time, and resistance to new processes.
van Baarle E, Hartman L, Rooijakkers S, et al. BMC Health Serv Res. 2022;22:1035.
A just culture in healthcare balances organizational and individual responsibility and accountability when medical errors occur. This qualitative study including five healthcare organizations in the Netherlands concluded that open communication and emotional responses are important components of just culture. Researchers also identified several challenges in fostering a just culture, including how individual accountability is addressed and how to combine transparency with patient and clinician privacy.
Weenink J-W, Wallenburg I, Hartman L, et al. BMJ Open. 2022;12:e061321.
There is a long-standing tension between health care regulation and just culture principles. This qualitative study explored the experiences of mental health professionals, managers and other healthcare organization staff, as well as inspectors, regarding the role of healthcare inspectors in enabling a just culture. Three themes emerged – (1) the role of the inspector as both a catalyst for learning and a potential barrier, (2) just culture involves relationships between different layers within and outside the organization, and (3) to enable just culture in which inspectors would strike a balance between organizational responsibility and timely regulatory intervention.
Weenink J-W, Wallenburg I, Leistikow I, et al. BMJ Qual Saf. 2021;30:804-811.
This qualitative study explored the impact of published inspection frameworks on quality and safety in nursing home care, dental care, and hospital care. Respondents noted the importance of the inspection framework design, the role of existing institutional frameworks, and how the frameworks can influence quality improvement across various organizational levels.
Kok J, Wallenburg I, Leistikow I, et al. Safety Sci. 2020;131:104914.
Measuring errors and adverse events in health care remains challenging, but is essential to achieving safe care. Using qualitative research and informal data, the authors discuss the importance of “soft signals” in patient safety risk assessment, which are warning signs that are not typically formally measured but that indicate problems with safe care, such as patient complaints about poor hygiene, observed disruptive staff behavior, and whistleblower complaints.
de Kam D, Kok J, Grit K, et al. Health Policy (New York). 2020;124:834-841.
Using qualitative and quantitative data, this study evaluated how incident reporting systems in the Netherlands contribute to organizational learning. The authors identified five core areas related to incident reporting: (1) changed staff attitudes and increased reporting; (2) improved sentinel event investigations; (3) participative learning; (4) local learning, and; (5) recommendations that improve care quality and safety.
Leistikow I, Bal RA. BMJ Qual Saf. 2020;29:869–872.
This article discusses how resilience and learning from things that go right (i.e., Safety-II) can influence interactions between healthcare providers and external regulatory systems. The authors present the five core concepts of Safety-II (definition of safety, safety management principles, human factors, accident investigation, and risk assessment) and depict their impact on accountability between healthcare providers and regulators.
Johannessen T, Ree E, Aase I, et al. BMC Health Serv Res. 2020;20:277.
A part of the SAFE-LEAD program to promote safety culture in Norwegian nursing homes and home care services, this paper describes perceived challenges by managers and employees in nursing home and home care services prior to intervention implementation. Focus groups with managers and employees reported several challenges, including: lack of care continuity; difficulties balancing budgetary and care needs; lack of communication between care systems and tools (such as different EHR systems that do not communicate), and; inadequate time leading to different error reporting cultures.
Johannessen T, Ree E, Strømme T, et al. BMJ Open. 2019;9:e027790.
Patients in long-term care are at risk for many types of adverse events. This article describes a leadership development intervention to promote safety culture in Norwegian nursing homes and home care services. A WebM&M commentary reviewed quality and safety issues in nursing homes.
Kok J, Leistikow I, Bal R. J Health Serv Res Policy. 2018;23:252-261.
Patient and family engagement enriches both incident reporting and adverse event investigations. These qualitative interviews with Dutch hospital managers highlight two assets patients and families offer during incident investigations: they provide details hospital staff cannot otherwise capture and the opportunity to regain trust. An Annual Perspective discussed novel approaches to engaging patients in their safety.
Leistikow I, Huisman F. J Patient Saf Risk Manag. 2018;23:139-141.
Work to reduce the negative impact of medical error began even before To Err Is Human raised awareness of patient safety. Providing a short history of patient safety work, this commentary explores the importance of culture change in health care and the role of patients in patient safety.
Leistikow I, Mulder S, Vesseur J, et al. BMJ Qual Saf. 2017;26:252-256.
Experiences from national incident reporting systems can help inform design of other programs. This commentary describes the Dutch national reporting system effort to encourage individual hospital learning through collecting comparative data on activities locally, assessing the reports, and monitoring improvements.
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.