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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 - 12 of 12 Results
Wolf MS, Smith K, Basu M, et al. J Pediatr Intensive Care. 2023;12:125-130.
Preventable harm continues to occur in high-risk care environments such as the pediatric intensive care unit (ICU). In this survey of 266 clinicians within a large pediatric healthcare system, 42% reported experiencing psychological distress after an adverse event, 22% reported absenteeism and 23% reported considering leaving the ICU. After involvement in an adverse event, respondents said that they would prefer peer support and the ability to step away from the unit to recover.
Loren DL, Lyerly AD, Lipira L, et al. J Patient Saf Risk Manag. 2021;26:200-206.
Effective communication between patients and providers – including after an adverse event – is essential for patient safety. This qualitative study identified unique challenges experienced by parents and providers when communicating about adverse birth outcomes – high expectations, powerful emotions, rapid change and progression, family involvement, multiple patients and providers involved, and litigious environment. The authors outline strategies recommended by parents and providers to address these challenges.
Berman L, Rialon KL, Mueller CM, et al. J Pediatr Surg. 2021;56:833-838.
Clinicians who are involved in an adverse even often experience emotional and psychological distress afterwards. A survey found that 80% of responding pediatric surgeons had personally experienced a medical error resulting in significant patient harm or death. Only one-quarter of those respondents were satisfied with the institutional support they received afterwards. Respondents cited numerous barriers (lack of trust, blame, shame) to receiving support.    
Berman L, Ottosen M, Renaud E, et al. J Pediatr Surg. 2019;54:1872-1877.
Morbidity and mortality (M&M) conferences are designed to review adverse events. They are one method by which physicians undergo peer review to evaluate their performance and can allow health systems to identify potential avenues for improving patient safety. A survey of pediatric surgeons found that while the M&M participation was high, few believed the process results in practice changes or preventing future events. M&Ms considered most effective had a structured approach, were data driven with loop closure, emphasized multidisciplinary participation, and served as an educational forum.
Heiss K, Clifton M. Semin Pediatr Surg. 2019;28:189-194.
This commentary examines how burnout and medical error contribute to diminished physician well-being. The authors highlight the importance of peer support in physician recovery and discuss the role of individuals, leaders, and organizations to recognize the problem and enhance the safety of the workplace.
Roybal J, Tsao KJ, Rangel S, et al. Pediatr Qual Saf. 2018;3:e108.
Research has shown that the effectiveness of surgical safety checklists in improving patient outcomes is mixed and may depend in part on implementation as well as providers' attitudes toward the importance of such checklists. In this survey study involving pediatric surgeons, 94% reported using surgical safety checklists but just 55% reported that they perceived such checklists to improve safety.
Bell SK, Etchegaray J, Gaufberg E, et al. Jt Comm J Qual Patient Saf. 2018;44:424-435.
Preventable harm can inflict lasting emotional damage on patients and families. Although many safety experts have examined how adverse events affect health care workers (second victims), patients' emotional experience of these events has garnered less scientific attention. The Agency for Healthcare Research and Quality convened diverse stakeholders, including patients, to identify research priorities to better elucidate how adverse events emotionally impact patients and families. They identified 4 priorities and delineated 20 steps organizations can take immediately to support those who experience adverse events, such as involving patients and families in developing solutions, incorporating emotional harm in organizational approaches to safety, and engaging patient advocates and leaders in improvement work. An Annual Perspective examined the shift toward a just culture in patient safety, which requires reckoning with the impact of errors on patients and families.
Gallagher TH, Etchegaray J, Bergstedt B, et al. Health Serv Res. 2016;51 Suppl 3:2537-2549.
Communication-and-resolution programs emphasize early disclosure of adverse events to patients and families, but implementing this patient-centered approach can be challenging. Researchers found that simulation was useful in helping stakeholders understand what patients and families experience after an adverse event and suggest that such understanding might lead to improved response.
Etchegaray J, Ottosen M, Aigbe A, et al. Health Serv Res. 2016;51 Suppl 3:2600-2614.
Adverse event investigation has not traditionally included patient perspectives. In this study, investigators interviewed patients and family members following an adverse event to determine whether they could identify any underlying causes of the incident. Each patient and family member was able to identify at least one contributing factor and make recommendations to address these underlying causes. The most frequent contributing cause reported was inadequate staff knowledge or qualification. However, the majority of participants were not involved in root cause analysis or other formal event investigation. This study is consistent with prior work that demonstrated the value of involving patients in error investigation. The authors conclude that patient perspectives should be included in event analysis.
Stein JE, Heiss K. Semin Pediatr Surg. 2015;24:278-82.
Shifting the focus from individual failures to system problems has produced new ways to reduce adverse events. This commentary discusses how human factors research has improved understanding about medical error and the role of teamwork training and safety culture in identifying and addressing safety problems in surgical practice.
Etchegaray J, Ottosen M, Burress L, et al. Health Aff (Millwood). 2014;33:46-52.
Patient engagement is increasingly recognized as a key element for patient safety. Although patients and family members may provide unique insights into adverse events, they are rarely asked to participate in medical error investigations, such as root cause analyses. Using detailed interviews, this study revealed that clinicians and hospital administrators generally support including patients and family members in these types of activities, but they are not sure how best to do so. A group of patients and health care experts at a national conference explored these findings and felt that patient involvement was desirable, but they identified many concerns and limitations with this approach. A recent AHRQ WebM&M perspective by Dr. Saul Weingart discussed the opportunities for patient engagement in patient safety.
DeRienzo CM, Frush K, Barfield ME, et al. Acad Med. 2012;87:403-10.
Reviewing evidence on transitions in care, this article describes how one university health system developed a comprehensive handoff curriculum to address educational needs in the context of changes to resident duty hours.