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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 - 20 of 219 Results
Stierman EK, O'Brien BT, Stagg J, et al. Qual Manag Health Care. 2023;32:177-188.
Maternal morbidity and mortality remain a significant problem in U.S. health care. This article describes Texas and Oklahoma’s adoption of a perinatal quality improvement initiative, including the implementation of the Alliance for Innovation of Maternal Health (AIM) patient safety bundles and use of teamwork and communication tools in obstetric units. Findings suggest that adoption of initiative components varies across obstetric units; the majority of units had standardized processes for serious events (obstetric hemorrhage, massive transfusion, severe hypertension) but fewer units offered regular training on effective teamwork and communication for their staff.
Bose S, Groat D, Dinglas VD, et al. Crit Care Med. 2023;51:212-221.
Medication discrepancies at discharge are a known contributor to hospital readmission, but nonmedication needs may also contribute. In this study, 200 survivors of acute respiratory failure were followed up 7-28 days post discharge to assess unmet nonmedication discharge needs (i.e., durable medical equipment, home health services, follow-up medical appointments). Nearly all patients had at least one unmet need, but this was not associated with hospital readmission or mortality within 90 days.
Gleason KT, Commodore-Mensah Y, Wu AW, et al. Nurse Educ Today. 2021;104:104984.
Massive online open courses (MOOCs) have the ability to reach a broad audience of learners. The Science of Safety in Healthcare MOOC was delivered in 2013 and 2014. At completion of the course, participants reported increased confidence on all six measured domains (teamwork, communication, managing risk, human environment, recognizing and responding, and culture). At 6 months post-completion, the majority agreed the content was useful and positively influenced their clinical practice, demonstrating that MOOCs are an effective interprofessional learning format.
Dixon-Woods M, Campbell A, Martin G, et al. Acad Med. 2019;94:579-585.
Disruptive and unprofessional behaviors are known threats to safety culture and contribute to burnout among health professionals. In response to an episode of serious misconduct by a clinician, an academic hospital implemented a structured effort to address disruptive behavior by developing mechanisms for frontline staff to voice their concerns. This article reports on the development and implementation of the effort, which focused on addressing longstanding aspects of institutional culture that were perceived as tolerating—and providing tacit endorsement of—prominent leaders who engaged in disruptive behavior.
Dietz AS, Salas E, Pronovost P, et al. Crit Care Med. 2018;46:1898-1905.
This study aimed to validate a behavioral marker as a measure of teamwork, specifically in the intensive care unit setting. Researchers found that it was difficult to establish interrater reliability for teamwork when observing behaviors and conclude that assessment of teamwork remains complex in the context of patient safety research.
Mathews SC, Sutcliffe K, Garrett MR, et al. J Healthc Risk Manag. 2018;38:38-46.
The patient safety community continues to struggle with implementation and sustainability of improvement programs. This commentary describes how one academic medical center used assessment tools to monitor, measure, and improve safety at the patient, provider, unit, and system levels in the organization.
Paine LA, Holzmueller CG, Elliott R, et al. J Healthc Risk Manag. 2018;38:36-46.
Health care executives and board members have a key role in safety improvement. This article describes the development of a tool and framework to assess the impact leadership decisions can have on organizational failure. The authors outline results and lessons learned from implementing the tool.
Martin G, Aveling E-L, Campbell A, et al. BMJ Qual Saf. 2018;27:710-717.
A work environment in which all team members feel comfortable speaking up about safety concerns is a key aspect of positive safety culture. Although formal mechanisms exist within health care institutions for raising safety issues, little is known about how such channels promote or discourage employees from speaking up. Researchers conducted interviews with 165 frontline staff and senior leaders working at three academic hospitals in two countries. They found that leaders viewed formal systems for raising concerns favorably, but other respondents felt uneasy reporting concerns through these channels. Such apprehension occurred especially if the concern was based on a general feeling that something might be wrong rather than hard evidence—what the authors refer to as "soft" intelligence. A PSNet perspective discussed how to change safety culture.
Mathews SC, Pronovost P, Biddison LD, et al. Am J Med Qual. 2018;33:413-419.
Organizational infrastructure is important to ensure sustainability of safety improvements. This commentary describes how one academic medical center integrated structures, processes, and frameworks to build connections within the organization and throughout the community to facilitate success of improvement initiatives.
Pitts SI, Maruthur NM, Luu N-P, et al. Jt Comm J Qual Saf. 2017;43:591-597.
Comprehensive unit-based safety programs have been shown to enhance safety in acute care settings. The investigators adapted this program for a primary care setting and report that safety culture improved following implementation of standard work and safety training. The authors did not report on patient outcomes.
Pauls LA, Johnson-Paben R, McGready J, et al. J Hosp Med. 2017;12:760-766.
The weekend effect refers to worse patient outcomes outside of usual business hours. This meta-analysis of 97 studies found that all-cause mortality is higher for patients hospitalized on the weekend compared to the workweek, even after adjustment for staffing, illness severity, and delays in procedures. A recent PSNet interview discussed the weekend effect in health care.
Basu L, Pronovost P, Molello NE, et al. Global Health. 2017;13:64.
The need to improve patient safety is an international concern. This commentary discusses the importance of partnership in reaching the overall goals of global patient safety and highlights experiences in Africa that demonstrate how high-income health care systems can learn from low-income hospitals.
Leslie M, Paradis E, Gropper MA, et al. Health Serv Res. 2017;52:1330-1348.
As implementation of comprehensive health information technology (IT) systems becomes more widespread, concern regarding the unintended consequences of such technologies has increased as well. Usability testing is helpful for optimizing implementation of health IT. Researchers analyzed the impact of health IT use on relationships among clinicians over a year-long period across three academic intensive care units. In the two units with higher health IT use, clinicians were more likely to work in an isolated manner, which was associated with an adverse effect on situational awareness, communication, and patient satisfaction. A previous PSNet perspective discussed some of the pitfalls in the development, implementation, and regulation of health IT and what can be learned to improve patient safety going forward.
Kane-Gill SL, Dasta JF, Buckley MS, et al. Crit Care Med. 2017;45:e877-e915.
Although technology has helped decrease medication errors, adverse drug events remain a significant source of harm. Patients in the intensive care unit (ICU) may be particularly vulnerable to medication errors due to the complex nature of their care. Prior research has shown that medication errors occur more frequently in the ICU and are more likely to cause serious patient harm or death. This clinical practice guideline highlights environmental changes and prevention strategies that can be employed to improve medication safety in the ICU. The authors also describe components of active surveillance that may augment detection of medication errors and adverse drug events. A previous WebM&M commentary discussed a case involving a serious medication error in the ICU setting.
Pronovost P, Wu AW, Austin M. JAMA. 2017;318:701-702.
Transparency in the reporting of quality and safety data demonstrates a commitment to improvement, learning, and patient empowerment regarding provider selection. This commentary suggests potential standards for hospitals to adopt for public reporting of their quality data and advocates for an external entity that reports how hospitals adhere to public reporting of quality measures.
McGinty EE, Thompson DA, Pronovost P, et al. J Nerv Ment Dis. 2017;205:495-501.
Patients with underlying psychiatric conditions may be particularly vulnerable to adverse events. This retrospective study analyzed 790 medical or surgical hospitalizations among adults with serious mental illness in Maryland hospitals over a 10-year period. Numerous patient, provider, and systems factors were correlated with adverse events. The authors suggest that improving safety in patients with mental illness will require multifaceted interventions.