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Patient Safety Network

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 177 Results
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    • Understanding the medication safety challenges for patients with mental illness in primary care: a scoping review.
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    • Ayre MJ, Lewis PJ, Keers RN. BMC Psychiatry. 2023;23:417.
    Medication safety in inpatient and outpatient settings is a major focus of patient safety efforts. This review included 79 studies on epidemiology, etiology, or interventions related to psychiatric medication safety in primary care (e.g., general practice, community pharmacy, long-term care). Most studies focused on older adults and potentially inappropriate prescribing. The authors recommend future research on wider age groups and underrepresented mental health diagnosis, such as attention deficient hyperactivity disorder (ADHD).
    Value of improving patient safety: health economic considerations for rapid response systems-a rapid review of the literature and expert round table.
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    • Subbe CP, Hughes DA, Lewis S, et al. BMJ Open. 2023;13:e065819.
    Failure to rescue refers to delayed or missed recognition of clinical deterioration, which can lead to patient complications and death. In this article, the authors used health economics methods to understand the health economic impacts associated with failure to rescue. The authors discuss the economic perspectives of various decision makers and how each group defines value. 
    Creating a stronger culture of safety within US community pharmacies.
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    • Lewis NJW, Marwitz KK, Gaither CA, et al. Jt Comm J Qual Patient Saf. 2023;49:280-284.
    Community pharmacies face unique challenges in ensuring patient safety. This commentary summarizes research on prescribing errors in community pharmacies and how a culture of safety in community pharmacies can drive improvements in prescribing safety.
    Frequency of medication administration timing error in hospitals: a systematic review.
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    • Pullam T, Russell CL, White-Lewis S. J Nurs Care Qual. 2023;38:126-133.
    Medication timing errors can lead to too-frequent or missed doses of medications and cause patient harm. This systematic review including 23 articles found that medication administration timing errors (defined in the majority of studies as administration greater than 60 minutes before or after the scheduled time) occur in up to 72.6% of medication administration errors.
    Factors differentiating nursing homes with strong resident safety climate: a qualitative study of leadership and staff perspectives.
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    • Engle RL, Gillespie C, Clark VA, et al. J Gerontol Nurs. 2023;49:13-17.
    Nurses’ willingness to speak up about resident safety concerns varies based on anticipated leadership response and support. Clinical and non-clinical staff at six Department of Veterans Affairs (VA) nursing homes with diverse safety climate ratings (high, medium, low) were interviewed to understand the association between resident safety and safety climate. Staff at high safety climate facilities described open communication and leadership responsiveness as contributors to a strong safety climate and willingness to speak up.
    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.
    Variation in detected adverse events using trigger tools: a systematic review and meta-analysis.
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    • Eggenschwiler LC, Rutjes AWS, Musy SN, et al. PLoS ONE. 2022;17:e0273800.
    Trigger tools alert patient safety personnel to potential adverse events (AE) which can then be followed up with retrospective chart review. This review sought to understand the variability in adverse event detection in acute care and study characteristics that may explain the variation. Fifty-four studies were included with a wide range of AEs detected per 100 admissions. The authors suggest developing guidelines for studies reporting on AEs identified using trigger tools to decrease study heterogeneity.
    Effect of a rapid response team on the incidence of in-hospital mortality.
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    • Factora F, Maheshwari K, Khanna S, et al. Anesth Analg. 2022;135:595-604.
    Rapid response teams (RRT) are designed to intervene at the earliest signs of clinical deterioration to prevent intensive care unit transfer, cardiac arrest, or death. This study presents the changes of in-hospital mortality rates following implementation of RRT, introduction of anesthesiologist-led RRT, and other policy changes. Results indicate a gradual decline of in-hospital mortality in the nine-year period following RRT introduction.
    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 … workplace safety; and workplace safety reporting. … Zebrak K, Yount N, Sorra J, et al. Development, pilot study, and psychometric …
    Association of patient and family reports of hospital safety climate with language proficiency in the US.
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    • Khan A, Parente V, Baird JD, et al. JAMA Pediatr. 2022;176:776-786.
    Parent or caregiver limited English proficiency (LPE) has been associated with increased risk of their children experiencing adverse events. In this study, limited English proficiency was associated with lower odds of speaking up or asking questions when something does not appear right with their child’s care. Recommendations for improving communication with limited English proficiency patients and families are presented.
    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.

    … about misdiagnoses when they occurred. … Famolaro T, Hare R, Tapia A, et al. Rockville, MD: Agency for Healthcare … Quality; April 2022. AHRQ Publication No. 22-0027. … Fan L, Ji S, Yount ND, Gray L, Zebrak K, Sorra J …
    Exploration of prescribing error reporting across primary care: a qualitative study.
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    • Hall N, Bullen K, Sherwood J, et al. BMJ Open. 2022;12:e050283.
    Reporting errors is a key component of improving patient safety and patient care. Primary care prescribers and community pharmacists in Northeast England were interviewed about perceived barriers and enablers to reporting medication prescribing errors, either internally or externally. Motivation, capability, and opportunity influenced reporting behaviors. 
    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.

    … measure was work pressure and pace. … Famolaro T,  Hare R, Tapia A, et al. Rockville, MD: Agency for Healthcare … 2022. AHRQ Publication No. 22-0017. … Taie-Tehrani S, Fan L, Liu H, Yount ND, Sorra J …
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