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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 21 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.
Kasick RT, Melvin JE, Perera ST, et al. Diagnosis (Berl). 2021;8:209-217.
Diagnostic errors can result in increased length of stay and unplanned hospital readmissions. To reduce readmissions, this hospital implemented a diagnostic time-out to increase the frequency of documented differential diagnosis in pediatric patients admitted with abdominal pain. Results showed marginal improvement in quality of differential diagnosis.
Perry MF, Melvin JE, Kasick RT, et al. J Pediatr. 2021;232:257-263.
Diagnostic errors remain an ongoing patient safety challenge and can result in patient harm. This article describes one large pediatric hospital's experience using a systematic methodology to identify and measure diagnostic errors. The quality improvement (QI) project used five domains (autopsy reports, root cause analyses (RCAs), voluntary reporting system, morbidity & mortality conference, and abdominal pain trigger tool) and adjudication by a QI team to identify cases of diagnostic error; Morbidity & mortality conferences, RCAs and abdominal trigger tool identified the majority (91%) of diagnostic errors.   
Grubenhoff JA, Ziniel SI, Cifra CL, et al. Pediatr Qual Saf. 2020;5:e259.
Over a 2-month period, researchers surveyed pediatric clinicians to asses their comfort discussing medical errors (involving both systems and individual clinician responsibility) during morbidity & mortality conferences and privately with their peers. Respondents were least comfortable publicly discussing errors and were significantly less comfortable discussing diagnostic errors compared with other medical errors. The greatest barriers to discussing errors involved public perception of clinical performance.   
Merandi J, Winning AM, Liao NN, et al. J Patient Saf Risk Manag. 2018;23:231-238.
Clinicians who experience negative emotional consequences after adverse events are considered second victims. This study evaluated health care provider satisfaction with a second victim peer support program in neonatal intensive care units. Many clinicians were unaware of the program but those who had used it expressed satisfaction. The authors conclude that specific efforts to raise awareness of and engagement with peer support for second victims is warranted.
Merandi J, Vannatta K, Davis T, et al. Pediatrics. 2018;141:e20180018.
The traditional approach to patient safety, frequently referred to as Safety-I, involved responding to adverse events and near misses after they happened. Safety-II is characterized by a more proactive approach that focuses on ensuring actions go as planned. This qualitative and exploratory study sought to understand whether Safety-II behaviors and system aspects contributed to the low adverse drug event rates observed in a single pediatric intensive care unit.
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.
Bartman T, McClead RE. Pediatr Rev. 2016;37:407-417.
This review discusses key patient safety concepts such as systems thinking, the role of leadership in a culture of safety, use of failure analysis tools, and the value of teams in establishing efforts and behaviors that result in sustainable improvement.
Storey MA, Weber RJ, Besco K, et al. Nutr Clin Pract. 2016;31:211-7.
Parenteral nutrition (PN) can result in patient harm if prepared or administered improperly. Recent shortages of PN ingredients have forced pharmacies to deviate from guidelines for safe PN preparation, but this study found that the incidence of errors has not increased.
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.
Taghon T, Elsey N, Miler V, et al. Jt Comm J Qual Patient Saf. 2014;40:326-334.
This commentary describes the development of a trigger tool initiative to detect and record adverse events in pediatric anesthesiology. The process included identifying which medications to track, creating a search mechanism, implementing the tool, and disseminating the data.
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.
Brilli RJ, McClead RE, Crandall W, et al. J Pediatr. 2013;163:1638-1645.
The focus of safety programs is shifting from targeting individual types of errors to building systems to ensure safety across multiple domains. In this study from a children's hospital, implementation of a broad-based organizational safety improvement program that emphasized safety culture resulted in a sustained decrease in different types of preventable harm over a 3-year period.