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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 108 Results
Hibbert PD, Molloy CJ, Schultz TJ, et al. Int J Qual Health Care. 2023;35:mzad056.
Accurate and reliable detection and measurement of adverse events remains challenging. This systematic review examined the difference in adverse events detected using the Global Trigger Tool compared to those detected via incident reporting systems. In 12 of the 14 included studies, less than 10% of adverse events detected using the Global Trigger Tool were also found in corresponding incident reporting systems. The authors of the review emphasize the importance of using multiple approaches and sources of patient safety data to enhance adverse event detection.
Ellis LA, Falkland E, Hibbert P, et al. Front Public Health. 2023;11:1217542.
Safety culture is recognized as an essential component of reducing or preventing errors and improving overall patient safety. This commentary calls for greater consistency in defining and measuring safety culture across settings. The authors describe challenges faced by patient safety professionals and researchers, and offer recommendations on overcoming them.
Healy A, Davidson C, Allbert J, et al. Am J Obstet Gynecol. 2023;228:b8-b17.
The demand for, and acceptance of, telemedicine solutions to provide services has grown substantially in recent years as safety profiles for the services are being defined. This guideline examines its use in pregnancy-related care, discusses the benefits and suggests actions to ensure patient safety during these encounters such as development of appropriate metrics and methods for vital-sign monitoring.
Ellis LA, Pomare C, Churruca K, et al. BMJ Open. 2022;12:e065320.
A strong safety culture encourages error reporting and supports a blame-free environment, and is frequently measured to develop appropriate interventions. This review identified nearly 900 studies that assessed hospital safety culture with response rates from 4% to 100%. The authors identify several factors that influence response rate: remote distribution (i.e., electronic or sent via mail), timing (e.g., beginning/end of resident rotations, COVID-19), and length of survey.
Healy M, Richard A, Kidia K. J Gen Intern Med. 2022;37:2533-2540.
The language used in progress notes in the electronic health record (EHR) can influence the attitudes of and treatment given by subsequent clinicians. This review describes words and phrases that are stigmatizing and provides neutral alternatives (e.g., person with substance use disorder instead of addict). Patients in minoritized groups may be especially impacted by stigmatizing language in progress notes.   
Ellis LA, Tran Y, Pomare C, et al. BMC Health Serv Res. 2021;21:1256.
This study investigated the relationship between hospital staff perceived sociotemporal structures, safety attitudes, and work-related well-being. The researchers identified that hospital “pace” plays a central role in understanding that relationship, and a focus on “pace” can significantly improve staff well-being and safety attitudes.
Churruca K, Ellis LA, Pomare C, et al. BMJ Open. 2021;11:e043982.
Safety culture has been studied in healthcare settings using a variety of methods. This systematic review identified 694 studies of safety culture in hospitals. Most used quantitative surveys, and only 31 used qualitative or mixed methods. Eleven themes were identified, with leadership being the most common; none of the methods or tools appeared to measure all 11 themes. The authors recommend that future research include both qualitative and quantitative methods.

Coulthard P, Thomson P, Dave M, et al. Br Dent J. 2020;229:743-747; 801-805.  

The COVID-19 pandemic suspended routine dental care. This two-part series discusses the clinical challenges facing the provision of routine dental care during the pandemic (Part 1) and the medical, legal, and economic consequences of withholding or delaying dental care (Part 2).  
Braithwaite J, Vincent CA, Garcia-Elorrio E, et al. BMC Med. 2020;18:340.
Delivering high-quality, safe healthcare requires coordination and integration of complex systems and activities. The authors propose three initiatives to further practical opportunities for transforming health systems across the world – a country-specific blueprint for change, tangible steps to reduce inequities within and across health systems, and learning from both errors and successes to improve safe care delivery.  
Staines A, Amalberti R, Berwick DM, et al. Int J Qual Health Care. 2021;33:mzaa050.
… Int J Qual Health Care … The authors of this editorial propose a … system to develop resilience . … Staines A, Amalberti R, Berwick DM, et al. COVID-19: patient safety and quality improvement skills to deploy during the surge. Int J Qual Health Care. Epub 2020 May 14. doi: …
Hibbert PD, Thomas MJW, Deakin A, et al. Int J Qual Health Care. 2020;32:184-189.
Based on 31 root cause analysis reports of surgical incidents in Australia, this study found that the most commonly retained surgical items were surgical packs (n=9) and drain tubes (n=8). While most retained items were detected on the day of the procedure (n=7), about 16% of items were detected 6-months or later post-procedure. The study found that complex or lengthy procedures were more likely to lead to a retained item, and many retained items, such as drains or catheters, occur in postoperative settings where surgical counts are not applicable.

Int J Qual Health Care. 2020;32(Supp1):1-105.

… impact conditions that affect quality and safety. … Int J Qual Health Care. 2020;32(Supp1):1-105. … G … T … HP … R … N … Y … J … F … C … W … E … E … R … O … C … NS … L … SB … Z … A … M … RP … Arnolda … Winata … Ting … Clay-Williams … Taylor … Tran … …
Mackay E, Jennings J, Webber S. BJA Edu. 2019;19:151-157.
Human factors affect medication delivery in the operating room. This review highlights the role of the anesthesiologist in safe medication administration and recommends strategies to reduce opportunities for error at each stage of medication administration, such as preoperative time-outs, preparation of medicines with color-coded syringe labels, patient identification prior to medication administration, and review of medications at handovers after administration.
Famolaro T, Yount ND, Hare R, et al. Rockville, MD: Agency for Healthcare Research and Quality; February 2019. AHRQ Publication No. 19-0027-EF.
The Agency for Healthcare Research and Quality developed the Nursing Home Survey on Patient Safety Culture to assess safety culture in long-term care facilities. This report summarizes survey data from nearly 10,500 staff working in 191 nursing homes. Respondents reported positive perceptions of resident safety and feedback and communication about incidents. Areas needing improvement included comfort with speaking up about safety concerns and sufficient staffing. As in prior studies of safety culture, managers reported higher safety culture scores compared to frontline staff. Most respondents reported that they would recommend the facility where they worked to friends and family. A past PSNet interview explored unique issues surrounding patient safety in the nursing home population.
Zaheer S, Ginsburg LR, Wong HJ, et al. BMJ Open Qual. 2018;7:e000433.
Establishing a culture of safety within health care organizations requires strong leadership support. This cross-sectional survey study of nurses, allied health professionals, and unit clerks working in the inpatient setting at a single hospital found that positive perceptions of senior leadership support for safety and positive perceptions of teamwork were associated with positive perceptions of patient safety. In addition, when staff perceived senior leadership support for safety to be lacking, the positive impact of direct managerial leadership on staff perceptions of patient safety was more pronounced.
Braithwaite J. BMJ. 2018;361:k2014.
In learning organizations, leadership behavior creates a supportive learning environment where concrete processes are in place to facilitate learning and encourage creativity among employees. Published in a series of quality improvement articles, this commentary suggests that a commitment to systems thinking and innovation is needed to achieve progress. Elements of a changed approach include a reduced focus on rules and policies and an enhanced effort to consider system interactions.