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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 - 14 of 14 Results
Madden C, Lydon S, Murphy AW, et al. Fam Pract. 2022;39:1095-1102.
Patient complaints and patient-reported incidents can help identify safety issues. This study compared clinician perceptions and patients’ accounts regarding patient safety incidents and identified a significant difference in perceptions about incident severity. Patients’ accounts of incidents commonly described deficiencies related to communication, staff performance, compassion, and respect.
Walshe N, Ryng S, Drennan J, et al. Int J Nurs Stud. 2021;124:104086.
Situation awareness refers to the degree to which perception matches reality. This narrative review explored how situation awareness has been defined and studied in healthcare, with a particular focus on nursing. Three overarching themes were identified: (1) individual, team and systems perspectives of situation awareness; (2) situation awareness and patient safety, and (3) communication tools, technologies and education to support situation awareness. The authors note that future research should reflect nurse’s work and the constrictions imposed on situation awareness by the demands of busy impatient wards.
O’Connor P, O’malley R, Lambe KA, et al. Int J Qual Health Care. 2021;33:mzab138.
Patient safety incidents occurring in prehospital care settings are gaining increasing attention. This systematic review including both peer-reviewed studies and grey literature found that the incidence rate of prehospital patient safety incidents is similar to hospital rates. The authors identified an average of 5.9 patient safety incidents per 100 records/transports/patients occurring in prehospital care; approximately 15% of these incidents resulted in patient harm. The authors discuss methodological challenges to preshopital care research and make recommendations for future studies.
Murphy A, Griffiths P, Duffield C, et al. J Adv Nurs. 2021;77:3379-3388.
Some adverse events are sensitive to aspects of nursing care, including pressure injuries, falls, hospital-acquired urinary tract infections, and medication administration errors. This retrospective study, based on patient discharge data from three Irish hospitals, characterized nursing-sensitive adverse events and associated costs. Results indicate that 16% of patients experienced at least one nurse-sensitive adverse event during their inpatient stay and that each additional nurse-sensitive adverse event was associated with a significant increase in length of stay. Extrapolated nationally, the authors estimate the economic burden of nurse-sensitive adverse events to the Irish health system to be €91.3 million annually.
O’Connor P, O’malley R, Oglesby A-M, et al. Int J Health Care Qual. 2021;33:mzab013.
Patient safety problems can be challenging to detect. This systematic review identified a variety of methods for measuring and monitoring patient safety in prehospital care settings (e.g., emergency medical services, air medical transport). They include surveys, patient record reviews, incident reporting systems, interviews, and checklists.
Madden C, Lydon S, O’Dowd E, et al. J Patient Saf. 2022;18:e51-e60.
Patient engagement has been recognized as a National Patient Safety Goal, and patients play a key role in ensuring safety in health care. This systematic review discusses 31 different patient-reported safety climate measures addressing items such as patient-centered care, health care costs, and comfort. The authors note that few measures report satisfactory validity and reliability, and few measures have had systematic usability testing. They suggest that future research focus on developing a stand-alone measure with high validity and reliability, and assess core safety climate domains from a patient perspective with an emphasis in primary care.
Lydon S, Power M, McSharry J, et al. Crit Care Med. 2017;45.
This systematic review examined efforts to improve hand hygiene in critical care settings. Although many interventions were effective, poor methodological rigor and bundled interventions limited identification of best practices. A previous PSNet perspective discussed approaches to measuring and improving hand hygiene, including human factors engineering.
Rafter N, Hickey A, Conroy RM, et al. BMJ Qual Saf. 2017;26:111-119.
In this retrospective study, researchers sought to understand the frequency of adverse events across Irish hospitals in the context of recent financial constraints. Review of 1574 records from inpatient admissions revealed that adverse events occurred in approximately 12% of cases and contributed to significantly increased costs.
O'Dea A, O'Connor P, Keogh I. Postgrad Med J. 2014;90:699-708.
This meta-analysis found that while there is clear evidence that team training had positive effects on knowledge, attitudes, and behaviors, there is little evidence that such improvements persist over time. Studies to date have not demonstrated that team training augments clinical outcomes. The authors call for larger, multicenter, longitudinal studies in order to draw clear conclusions about the impact of such training on safety.
O'Connor P, Byrne D, O'Dea A, et al. Jt Comm J Qual Patient Saf. 2013;39:426-431.
Previous research has shown that junior physicians may be unwilling to question senior physicians. This article describes an educational program for interns that successfully improved knowledge and attitudes regarding speaking up but had not yet measurably changed behaviors.