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 76 Results

Middle manager responses to hospital co-workers' unprofessional behaviours within the context of a professional accountability culture change program: a qualitative analysis.

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Bagot KL, McInnes E, Mannion R, et al. BMC Health Serv Res. 2023;23:1012.

Unprofessional behavior can have a detrimental effect on coworkers, culture, and patient safety. This qualitative study presents perspectives of middle managers in hospitals that implemented a program allowing and encouraging workers to report unprofessional, as well as positive, behavior. Themes included staying silent but active (e.g., avoiding the unprofessional colleague), history and hierarchy, and double-edged swords (e.g., pros and cons of anonymous reporting).

Activating pharmacists to reduce the frequency of medication-related problems (ACTMed): a stepped wedge cluster randomised trial.

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Spinks J, Violette R, Boyle DIR, et al. Med J Aust. 2023;219:325-331.

Medication safety in ambulatory care settings is an area of growing concern. This article describes ACTMed (ACTivating primary care for MEDicine safety), a cluster randomized trial set in Australia which intends to improve medication safety in primary care settings. The ACTMed intervention will use health information technology (e.g., clinical indicator algorithms), guideline-based clinical recommendations, shared decision-making, and financial incentives to reduce serious medication-related harm, medication-related hospitalizations, and death.

Pilot implementation of a health equity checklist to improve the identification of equity-related adverse events.

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Patient Safety Innovation March 29, 2023

Minoritized patients continue to experience disproportionately high rates of maternal morbidity and mortality. This hospital developed a health-equity checklist to identify if bias and/or social determinants of health played a role in preventable adverse events.

Short- and long-term effects of an electronic medication management system on paediatric prescribing errors.

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Westbrook JI, Li L, Raban MZ, et al. NPJ Digit Med. 2022;5:179.

Pediatric patients are particularly vulnerable to medication errors. This cluster randomized controlled trial examined the short- and long-term impacts of an electronic medication management (eMM) system implemented at one pediatric referral hospital in Australia. Findings suggest that eMM implementation did not reduce medication errors in the first 70 days of use, but researchers observed a decrease in medication errors one year after implementation, suggesting long-term benefits.

2022 Updated Results for the AHRQ Surveys on Patient Safety Culture Workplace Safety Supplemental Item Set for Hospitals.

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Hare R, Tyler ER, Tapia A, Fan L, et al. Rockville, MD: Agency for Healthcare Research and Quality; November 2022. AHRQ Publication No. 22(23)-0008.

The AHRQ Surveys on Patient Safety Culture™ (SOPS®) Hospital Survey Hospital Survey on Patient Safety Culture ask health care providers and staff about the extent to which their organizational culture supports patient safety. The SOPS Workplace Safety Supplemental Item Set for Hospitals was designed for use in conjunction with the AHRQ Hospital Survey to help hospitals assess the extent to which their organization’s culture supports workplace safety for providers and staff. This data analysis found “Protection From Workplace Hazards” as the highest-scoring composite measure and “Addressing Workplace Aggression From Patients or Visitors” as the lowest-scoring composite measure. An average of 34% of healthcare providers and staff experienced symptoms of “Work Stress/Burnout” which represents a 4-percentage point increase from the 2021 pilot study results.

Surveys on Patient Safety Culture (SOPS) Hospital Survey 2.0: 2022 User Database Report.

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Hare R, Tapia A, Tyler ER, Fan L, et al. Rockville, MD: Agency for Healthcare Research and Quality; October 2022. AHRQ Publication No. 22(23)-0066.

Instituting a culture of safety is fundamental to ensuring patient and staff safety. The AHRQ Surveys on Patient Safety Culture™ (SOPS®) Hospital Survey is a validated survey that has been widely used to assess patient safety culture since 2004. The 2022 report includes data from 400 hospitals. The highest “percent positive” composite measure scores included both effective teamwork and supervisor, manager, or clinical leader support for suggestions for improving patient safety, and addressing patient safety concerns. Overall, when asked to rate their unit/work area on patient safety, 67 percent of respondents rated their unit/work area as “Excellent” or “Very Good.”

Changes in unprofessional behaviour, teamwork, and co-operation among hospital staff during the COVID-19 pandemic.

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Westbrook JI, McMullan R, Urwin R, et al. Intern Med J. 2022;52:1821-1825.

The COVID-19 pandemic dramatically impacted team functioning in healthcare settings. This survey of nearly 1,600 clinical and non-clinical staff at five Australian hospitals did not identify any perceived increases in unprofessional behaviors during the pandemic and 44% of respondents cited improvements in teamwork.

Development, pilot study, and psychometric analysis of the AHRQ Surveys on Patient Safety Culture (SOPS) Workplace Safety Supplemental Items for Hospitals.

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Zebrak K, Yount N, Sorra J, et al. Int J Environ Res Public Health. 2022;19:6815.

… Int J Environ Res Public Health … AHRQ’s Hospital Survey on Patient Safety (SOPS) is used by … workplace safety; and workplace safety reporting. … Zebrak K, Yount N, Sorra J, et al. Development, pilot study, and …

2022 Updated Results for the AHRQ Surveys on Patient Safety Culture (SOPS) Diagnostic Safety Supplemental Items.

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Famolaro T, Hare R, Tapia A, et al. Rockville, MD: Agency for Healthcare Research and Quality; April 2022. AHRQ Publication No. 22-0027.

A strong safety culture affects practice and learning in health care. This survey of over 1,000 clinicians and staff in 110 medical offices examined the extent to which elements of safety culture support safe diagnosis. Key findings demonstrate strengths in specialist consultation and test result communication. Identified weaknesses included lack of discussions about misdiagnoses when they occurred.

Surveys on Patient Safety Culture (SOPS) Medical Office Survey: 2022 User Database Report.

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Famolaro T, Hare R, Tapia A, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2022. AHRQ Publication No. 22-0017.

The AHRQ Medical Office Survey on Patient Safety Culture is designed to assess safety culture in outpatient clinics. The 2022 comparative data report includes data from 1,100 US medical offices and over 13,000 providers and staff. The highest-scoring composite measures are patient care tracking/follow-up and teamwork. Like the 2020 report, the lowest-scoring measure was work pressure and pace.

Surveys on Patient Safety Culture™ (SOPS®) Ambulatory Surgery Center Survey: 2021 User Database Report.

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Famolaro T, Hare R, Tapia A, Yount et al. Rockville, MD: Agency for Healthcare Research and Quality; December 2021. AHRQ Publication No. 22-0004.

Ambulatory surgery centers harbor unique characteristics that affect safety culture. This analysis from the Agency for Healthcare Research and Quality (AHRQ) shares results of 235 ambulatory surgery centers (ASCs) participating in the Surveys on Patient Safety Culture (SOPS) Ambulatory Surgery Center Survey. Most respondents (92%) rated their organization as committed to learning and continuous improvement.

Malpractice cases in breast surgery: an assessment of litigation involving surgeons.

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Fan B, Pardo J, Yu-Moe CW, et al. Ann Surg Oncol. 2021;28:8109-8115.

While prior research has described malpractice cases related to breast cancer diagnosis and treatment, this study sought to identify errors specifically related to breast cancer surgical procedures. Plastic surgeons were the most commonly named provider type (64%), error in surgical treatment was the most common allegation (87%), and infection, cosmetic injury, emotional trauma, foreign body, and nosocomial infection were the top 5 injury descriptions.

Trauma Resuscitation Using in situ Simulation Team Training (TRUST) study: latent safety threat evaluation using framework analysis and video review.

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Petrosoniak A, Fan M, Hicks CM, et al. BMJ Qual Saf. 2021;30:739-746.

… capacity, and task-specific issues. … Petrosoniak A, Fan M, Hicks CM, et al. Trauma Resuscitation Using in situ …

Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions.

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Morris AH, Stagg B, Lanspa M, et al. J Am Med Inform Assoc. 2021;28:1330-1344.

Clinical decision support systems are designed to improve clinical decision-making. The authors of this commentary suggest an alternative, eActions, to reduce clinician burden and increase replicability. Dissemination and use of eActions could contribute to improved clinical care quality and research.

Medical Office Survey: 2020 User Database Report.

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Famolaro T, Hare R, Thornton S, et al. Surveys on Patient Safety CultureTM (SOPSTM). Rockville, MD: Agency for Healthcare Research and Quality; March 2020. AHRQ Publication No. 20-0034.

… associated with productivity pressures in health care. … Famolaro T, Hare R, Thornton S, et al. Surveys on Patient Safety CultureTM (SOPSTM). …

Surveys on Patient Safety Culture(TM) (SOPS®) Hospital Survey 2021 User Database Reports.

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Famolaro T, Hare R, Yount ND, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2021. AHRQ Publications Nos. 21-0016(1.0) and 21-0017(2.0).

Establishing culture of safety is an essential component to develop high reliability organizations and ensure patient safety. The AHRQ Hospital Survey on Patient Safety Culture is a validated survey that examines organizational perceptions about safety culture ranging from communication about errors to teamwork within and across units. In 2019, AHRQ released a new version, the SOPS Hospital Survey 2.0. The 2021 SOPS Hospital 1.0 Database Report includes 320 hospitals and 191,977 respondents, and the 2.0 Database Report includes 172 hospitals and 87,856 respondents. In both reports, areas of strength included teamwork within units and leadership, and respondents reported concerns about handoffs and transitions. The 1.0 Database Report also noted concerns about leadership expectations and actions for promoting safety, and the 2.0 Database Report noted concerns about staffing and work pace.

Linking patient safety culture to quality ratings in the nursing home setting.

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Yount N, Zebrak KA, Famolaro T, et al. J Appl Gerontol. 2021;41:73-81.

… which is consistent with other earlier findings. … Yount N, Zebrak KA, Famolaro T, et al. Linking patient safety culture to quality ratings …

Survey of cancer care providers' attitude toward care for older adults with cancer during the COVID-19 pandemic.

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BrintzenhofeSzoc K. J Geriatr Onco. 2021;12:196-205.

Patients with cancer and their providers face numerous challenges during the COVID-19 pandemic. This survey of multidisciplinary providers treating patients with cancer identified several challenges to safe care provision, including lack of access to guidelines specifically addressing the management of older adults with cancer during the pandemic, delays in necessary treatment, and barriers to the use of telehealth.

More than an apple a day: factors associated with avoidance of doctor visits among transgender, gender nonconforming, and nonbinary people in the USA.

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Lerner JE, Martin JI, Gorsky GS. Sex Res Social Pol. 2020;18:409-426.

This study used national survey data to examine avoidance of healthcare services among transgender, gender nonconforming, and non-binary people. Researchers found that nearly one quarter of respondents reported not seeking healthcare when necessary because they anticipated being disrespected or mistreated by healthcare professionals. Previous experience with certain discriminatory behavior such as invasive questions, refusal of care, verbal harassment, as well as cost and needing to educate providers, were strong predictors of healthcare avoidance.

Associations between double-checking and medication administration errors: a direct observational study of paediatric inpatients.

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Westbrook JI, Li L, Raban MZ, et al. BMJ Qual Saf. 2021;30:320-330.

… but the association was not significant . These f inding s raise questions about the benefits compared to single-checking. … Westbrook JI, Li L, Raban MZ, et al. Associations between double-checking and …

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