Skip to main content

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.

Search All Content

Search Tips
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Search By Author(s)
PSNet Original Content
Commonly Searched Resource Types
Additional Filters
Displaying 1 - 20 of 66 Results
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.
Lin M, Horwitz LI, Gross RS, et al. J Patient Saf. 2022;18:e470-e476.
Error disclosure is an essential activity to addressing harm and establishing trust between clinicians and patients. Trainees in pediatric specialties at one urban medical center were provided with clinical vignettes depicting an error resulting in a safety event or near-miss and surveyed about error classification and disclosure. Participants agreed with disclosing serious and minor safety events, but only 7% agreed with disclosing a near miss event. Trainees’ decisions regarding disclosure considered the type of harm, parental preferences, ethical principles, and anticipatory guidance to address the consequences of the error.
Wang E, Arnold S, Jones S, et al. JAMA Netw Open. 2022;5:e2142382.
This study examined whether a full-integration approach to a hospital merger and acquisitions (consisting of early leadership integration, rapid transition to electronic health record systems, local ownership of quality metrics, dashboards featuring system goals and actional analytics, and use of value-based and analytic-driven interventions) improved patient outcomes. Compared to the situation pre-merger, findings show that in-hospital mortality and hospital-acquired infection rates were lower, while patient satisfaction were higher after the full-integration merger.
Santhosh L, Lyons PG, Rojas JC, et al. BMJ Qual Saf. 2019;28:627-634.
This mixed-methods study combined survey data from resident physicians with a comparison of process maps from three academic medical centers to assess handoffs from intensive care units to medical wards. The vast majority of survey respondents could recall at least one adverse event related to suboptimal handoff communication between these settings, and review of the process maps revealed safety gaps in existing processes.
Chacko KM, Halvorsen AJ, Swenson SL, et al. Am J Med Qual. 2018;33:405-412.
… journal of the American College of Medical Quality … Am J Med Qual … Engaging trainees in quality improvement efforts … been an important area of focus within graduate medical education, but less is known about how health system … program directors regarding health system support for and alignment with graduate medical education quality …
Matern LH, Farnan JM, Hirsch KW, et al. Simul Healthc. 2018;13:233-238.
Training resident physicians to use structured handoff tools reduces errors in the care of hospitalized patients. Researchers developed a handoff simulation incorporating the types of noise and distractions that are ubiquitous in hospitals. After training, distracted residents provided the same quality handoff as those able to communicate in a quiet place.
Wray CM, Chaudhry S, Pincavage A, et al. JAMA. 2016;316:2273-2275.
… Research suggests that standardization , dedicated space, and supervision improve resident handoffs , but less is known … Investigators surveyed residency program directors and found significant variation in the implementation of recommended handoff practices and educational strategies. …
Martin SK, Tulla K, Meltzer DO, et al. J Grad Med Educ. 2017;9:706-713.
This survey study examined remote electronic health record use by attending physicians for resident supervision. Nearly all respondents reported accessing the electronic health record remotely. Of these, 92% reported discovering clinically relevant information that the residents had not conveyed to them. The authors conclude that this "backstage" supervision requires further study to identify best practices for safety and education.
Wang JS, Fogerty RL, Horwitz LI. PLoS One. 2017;12:e0186075.
This secondary data analysis found that most patients admitted to the hospital have their medications changed to another medication of the same class to be consistent with the hospital formulary. Researchers found that patients who undergo this therapeutic interchange are more likely to have errors in medication reconciliation at the time of hospital discharge compared to patients whose medications are not changed. The authors suggest that improved information technology may address this patient safety concern.
Krumholz HM, Wang K, Lin Z, et al. N Engl J Med. 2017;377:1055-1064.
Avoiding readmissions has been an important safety goal, especially since Medicare has implemented nonpayment policies. Patient factors like health literacy and access to outpatient follow-up care have been implicated in previous research on readmissions. In contrast, this study sought to determine whether hospital quality affects readmission rates. By examining patients with multiple admissions for the same diagnosis but at different hospitals, they were able to focus on the effect of the hospital alone. Hospitals were divided into four tiers based on their known overall rate of readmissions, and then investigators assessed whether a given patient was more or less likely to be readmitted based on these tiers. They found a higher likelihood of a given patient being readmitted at hospitals in the tier with the most readmissions compared to those hospitals in the lowest readmission tier. The authors conclude that hospital readmissions are in part due to hospital factors as well as individual factors. This finding suggests that targeting hospital safety practices could reduce readmissions.
Yaghmour NA, Brigham T, Richter T, et al. Acad Med. 2017;92:976-983.
… cause of death among resident physicians is cancer, and the second leading cause of death is suicide . Investigators note that there are fewer deaths overall and from suicide compared to age- and gender-matched general … and interventions to prevent burnout and provide support for medical trainees. …
Myers JS, Tess A, McKinney K, et al. J Grad Med Educ. 2017;9:9-13.
It is critical to educate trainees about patient safety. In this study, researchers described lessons learned from creating a leadership role that bridges quality and safety activities with graduate medical education in each of their institutions. Key responsibilities included clinical oversight, faculty development, and educational innovation. The authors advocate for further evaluation of this safety and education leadership role to determine its impact on medical education and patient outcomes.
Desai NR, Ross JS, Kwon JY, et al. JAMA. 2016;316:2647-2656.
This retrospective analysis of Medicare claims data found that the decrease in readmissions following the Hospital Readmission Reduction Program occurred across target conditions and other diagnoses. Hospitals penalized by the Centers for Medicare and Medicaid Services had greater reductions in readmissions for the targeted conditions. These results support the effectiveness of the nonpayment policy.
Fargen KM, Drolet BC, Philibert I. Acad Med. 2016;91:858-64.
… of American Medical Colleges … Acad Med … Disruptive and unprofessional behavior results in a poor culture of … of unprofessional behaviors among medical students and residents. Although many studies show that trainees commit professionalism violations fairly regularly—for example, multiple studies show that up to 50% of …