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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 - 11 of 11 Results
Peadon R (R), Hurley J, Hutchinson M. Safety Sci. 2020;125:104648.
A key tenet of safety culture is the premise that all team members should speak up about safety concerns; however, prior research has found that many healthcare workers do not feel comfortable speaking up. This systematic review explored the mechanisms influencing speaking up behaviors while witnessing medical errors. Several studies identified hierarchies as a barrier to speaking up, particularly among trainees, due to fear of retribution, being exposed, or undermining senior clinicians. The findings from this review reinforce the concept that communication is a learned skill that requires ongoing training. The authors suggest that future studies on speaking up behavior examine the causal mechanisms influencing speaking up behavior.
Ryan L, Jackson D, Woods C, et al. J Adv Nurs. 2019;75:1151-1161.
This review examines international evidence on the role nurses play in implementing intentional rounds. The authors explore areas of impact, including patient satisfaction, falls, and hospital-acquired pressure ulcers, and conclude that benefits have been realized from enhanced rounding practice, but further research is needed. They offer implications for practice and highlight the role of leadership, research, and education in reducing the negative expectations of rounding initiatives.
Ferguson C, Hickman L, Macbean C, et al. J Clin Nurs. 2019;28:2365-2368.
Patient misidentification can result in incorrect diagnosis, treatment, and medication administration. This commentary discusses the practice of auditing patient identification wristbands to assess compliance and accuracy. The authors suggest that technological interventions such as smartphone facial recognition and barcode technologies be considered as strategies to avoid patient misidentification.
Alzyood M, Jackson D, Brooke J, et al. J Clin Nurs. 2018;27:1329-1345.
Patients are being encouraged to speak up about safety concerns as part of broader efforts to engage patients in safety programs. This review of studies of patient engagement in hand hygiene programs found some evidence that patients are willing to raise concerns regarding hand hygiene, especially with nurses, but also identified factors that might inhibit patient willingness to discuss these issues with their providers.
Hutchinson M, Jackson D, Wilson S. Nurs Inq. 2018;25:e12225.
Lack of consensus regarding whether some types of health care–acquired harm are unavoidable influences design and implementation of patient safety initiatives. This commentary spotlights concerns that normalizing harm as unavoidable can hinder investigation of incidents.
Hayes C, Jackson D, Davidson PM, et al. J Clin Nurs. 2015;24:3063-76.
This systematic review found clear consensus that disruptions worsen the safety of medication administration by nursing, and interventions to reduce such interruptions can improve safety. Investigators identified effective management of unavoidable interruptions as a gap in current research and training for nurses.
Hayes C, Power T, Davidson PM, et al. Nurse Educ Today. 2015;35:981-6.
Interruptions pose a significant safety hazard for health care providers performing complex tasks and increase the risk of errors. This commentary describes a simulated training initiative to help prepare nursing students for experiencing and responding to interruptions during medication administration.