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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 25 Results
Winning AM, Merandi J, Rausch JR, et al. J Patient Saf. 2021;17:531-540.
Healthcare professionals involved in a medical error often experience psychological distress. This article describes the validation of a revised version of the Second Victim Experience and Support Tool (SVEST-R), which was expanded to include measures of resilience and desired forms of support.
Bartman T, Merandi J, Maa T, et al. Jt Comm J Qual Patient Saf. 2021;47:526-532.
Safety II is a proactive approach to improving patient safety by learning from what goes right in healthcare. A US children’s hospital developed three tools for frontline clinicians to recognize, mitigate, and learn from potential safety issues at the bedside.
Winning AM, Merandi JM, Lewe D, et al. J Adv Nurs. 2018;74:172-180.
Errors can take a significant emotional toll on health care workers, often referred to as the second victim effect. In this survey study, researchers found that neonatal intensive care unit providers involved an adverse event were more likely to experience anxiety and depression. Perceiving coworkers as supportive appeared to moderate this effect.
Rodriquez J, Scott SD. Jt Comm J Qual Patient Saf. 2018;44:137-145.
Clinicians who experience emotional distress after adverse events or medical errors are referred to as second victims. Researchers surveyed health care providers whose career choices were impacted by involvement in an adverse event. In keeping with prior research, respondents reported a lack of support after the event.
Wu AW, Shapiro J, Harrison R, et al. J Patient Saf. 2020;16:65-72.
Word choice can impact buy-in for programs and integrating concepts across an organization. This review examines the term "second victim" as a label for health professionals involved in adverse events. The authors explore both constructive and negative reactions to the term and suggest that context and culture affect the appropriateness of its use.
Mira JJ, Lorenzo S, Carrillo I, et al. Int J Qual Health Care. 2017;29:450-460.
This review study examined policies to address the consequences of adverse events for patients, providers, and organizations. The methods included focus groups and a literature review. The team generated recommendations such as involving patients in event investigation, providing time away from usual work for second victims, and establishing a crisis plan for organizations.
Merandi J, Liao NN, Lewe D, et al. Pediatr Qual Saf. 2019;2:e031.
This study reports on the implementation of a second victim support program for staff at a pediatric hospital. Building on a previously described model, the institution developed a system to provide support for staff involved in errors. Over a 2-year period, more than 200 staff received support and survey responses indicated that employees found the program to be beneficial.
Burlison JD, Quillivan RR, Scott SD, et al. J Patient Saf. 2021;17:195-199.
Health care organizations are increasingly recognizing the importance of providing support to second victims. In this survey study, researchers found that when respondents perceived their organization as supportive to second victim distress, they were less likely to express a desire to leave their job or to require time away from work. The authors point out that this is the first study to look at the impact of the second victim experience on work-related outcomes.
Quillivan RR, Burlison JD, Browne EK, et al. Jt Comm J Qual Patient Saf. 2016;42:377-386.
The second victim phenomenon describes the distress health care providers can experience after adverse events. This survey of 358 nurses at a single pediatric hospital found that those working in a stronger safety culture were less likely to report distress after involvement in a patient safety event. The authors suggest that bolstering safety culture can help prevent negative effects of second victim experiences.
Scott SD, McCoig MM. J Healthc Risk Manag. 2016;35:6-13.
Health care workers who experience emotional consequences after being involved in a medical error are known as second victims. This commentary reviews the stages of recovery that such health care workers experience, determined by a hospital-based program to provide immediate support for second victims. A PSNet perspective offers insights from one of the authors about this program.
Krzan KD, Merandi J, Morvay S, et al. Am J Health Syst Pharm. 2015;72:563-7.
The term "second victims" was coined to describe clinicians who commit errors, acknowledging the significant emotional impact that errors can have on the clinicians involved. A structured program to provide immediate support to clinicians affected by medical errors was well received by the pharmacy staff at a pediatric hospital.
McClead RE, Catt C, Davis T, et al. J Pediatr. 2014;165:1222-1229.e1.
This time-series analysis demonstrated that a multicomponent intervention including voluntary reporting, trigger tool review, and pharmacy process improvement led to a significant decrease in adverse drug events in an inpatient setting. These findings underscore the need for a comprehensive approach to medication safety.
Burlison JD, Scott SD, Browne EK, et al. J Patient Saf. 2017;13:93-102.
The second victim phenomenon—the damaging psychological impacts of errors on the clinicians who are involved—has been well documented in the literature. This study presents the development and validation of a survey tool, the SVEST, to examine clinicians' experiences with errors and evaluate the effectiveness of approaches to aid second victims.
Morvay S, Lewe D, Stewart B, et al. Jt Comm J Qual Patient Saf. 2014;40:39-45.
Retrospective analysis of adverse events is traditionally performed using tools such as root cause analysis. These methods are limited if—as is often the case—the analysis is performed weeks to months after the incident, since those involved may not recall the events surrounding the error accurately. This article describes how a children's hospital implemented medication event huddles as a way of analyzing adverse drug events contemporaneously. Huddles, which included nursing and pharmacy leadership along with the unit's frontline staff, took place immediately after any clinical adverse drug event and used a formal protocol to identify active and latent errors leading to the incident. The huddles were viewed as useful and nonpunitive by frontline staff and management and led to several system improvements. Prior studies have discussed how huddles may be used to enhance situational awareness and detect other latent safety threats.