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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 32 Results
Jensen JF, Ramos J, Ørom M‐L, et al. J Clin Nurs. 2023;32:7530-7542.
Crisis (or crew) resource management (CRM) training focuses on improvement of non-technical skills such as communication, teamwork, and situational awareness. This quality improvement project consisted of simulation-based CRM training in the context of intensive care unit admission. Interviews with participants, conducted three months after the simulation, revealed several themes including reflections on patient safety. Participants described positive changes in workflow, professional standards, and smoother and controlled processes.
Axelsen MS, Baumgarten M, Egholm CL, et al. J Adv Nurs. 2023;Epub Jun 30.
Rapid response teams (RRT) are activated, typically by nurses, when a patient demonstrates signs of imminent clinical deterioration, in order to prevent death or transfer to the intensive care unit (ICU). This study asks ICU managers about their perceptions of RRT beyond the stated goal of preventing patient deterioration. They describe the RRT as providing valuable education for new nurses and physicians and enhancing cohesion between the ICU and other wards. However, nurse managers stated they wanted more data and feedback from executive leadership.
Schram A, Paltved C, Christensen KB, et al. BMJ Open Qual. 2021;10:e001183.
Simulation training is increasingly used as an educational tool and can improve teamwork and safety culture. Set at two Danish hospitals, this study evaluated perceived safety culture before and after a four-day in situ simulation training emphasizing team training, communication, and leadership. After the training, safety attitudes improved, but the effect was more pronounced at the acute care hospital compared to the hospital handling mainly elective procedures.
Kjaergaard-Andersen G, Ibsgaard P, Paltved C, et al. Int J Health Care Qual. 2021;33:mzaa148.
Simulation training is used by hospitals to improve patient care. This study describes the experience of one Danish hospital shifting from simulation training at external centers to in situ training. The shift to in situ training identified several latent safety threats (e.g., equipment access, lack of closed-loop communication, out-of-date checklists) and these findings led to practice changes.  

Hallbeck MS, Paquet V, eds. Appl Ergon. 2019;78:248-308.

Surgery requires specialized approaches to understand and prevent failure. This special issue features the work of multidisciplinary research teams that explored human factors and ergonomic concerns in the operating room that affect communication between robotic-assisted surgery teams, physical resilience of teams, instrument design and use, and poor implementation of briefings as improvement opportunities.
Kristensen RU, Nørgaard A, Jensen-Dahm C, et al. J Alzheimers Dis. 2018;63:383-394.
Prior research has shown that polypharmacy in elderly patients with dementia is associated with a greater risk of functional decline. This cross-sectional study of Danish patients age 65 and older found that polypharmacy and potentially inappropriate medication use were common in this population and were more frequent among patients with dementia.
Phipps AR, Paradis M, Peterson KA, et al. Jt Comm J Qual Patient Saf. 2018;44:334-340.
This study chronicles the effort made by a children's hospital to enhance safety across all levels of the organization. Spurred by local data showing above-average rates of hospital-acquired complications, the hospital joined a quality improvement collaborative to implement a systemwide patient safety program. The interventions emphasized developing a culture of safety and included engaging leadership in improving safety through executive walk rounds, revamping the institution's root cause analysis and event reporting systems, and recognizing and rewarding staff for safety improvements. The program was associated with a significant decline in safety events. A prior publication found that safety event rates declined overall for the entire cohort of collaborative participants (33 hospitals in total).
Duong JA, Jensen TP, Morduchowicz S, et al. J Gen Intern Med. 2017;32:654-659.
Patients hospitalized and cared for by an overnight physician, known as "holdover admissions," are increasingly common due to duty hours limitations, and they necessitate handoffs between admitting physicians and the new primary medical team. This qualitative study identified unmet needs in holdover handoffs, including assessment of diagnostic uncertainty, standardization, and feedback. The authors call for more scrutiny of holdover handoffs.
Ehlers LH, Simonsen KB, Jensen MB, et al. Int J Qual Health Care. 2017;29:406-411.
Hospital accreditation surveys are critical to identifying and ameliorating safety risks. This trial in Denmark randomized hospitals to receive either announced or unannounced hospital accreditation surveys. Investigators found no differences in adherence to performance indicators among hospitals who received unannounced compared to planned survey visits. They conclude that unannounced visits are no more likely to detect quality concerns.
Denson JL, Jensen A, Saag HS, et al. JAMA. 2016;316:2204-2213.
Handoffs are ubiquitous in hospital care and a recognized risk factor for adverse events. Most research on handoffs has focused on care transitions from the primary clinician to a covering clinician, but studies have also demonstrated the potential for harm associated with changes in the entire team of care (such as at the end of the academic year). In academic hospitals, clinician teams switch on a predictable schedule, often at the end of the month, when residents complete a rotation. This study analyzed the outcomes of more than 200,000 inpatients at Veterans Affairs hospitals to determine if end-of-rotation team changes were associated with clinical harm. Investigators found a striking increase in in-hospital mortality among patients whose hospitalization spanned the end of a rotation (and thus were exposed to a resident team change during their hospital stay), which persisted for up to 90 days after discharge. The accompanying editorial notes that some of the mortality increase may be accounted for by the fact that patients who are more seriously ill and have longer hospitalizations may have been at higher risk of death independent of the team change. Nevertheless, since there are no standards for patient handoffs at the end of a rotation, poor information transfer or cognitive heuristics (such as anchoring bias) may have led to preventable adverse events. The editorial authors advocate for more research into the mechanisms of this mortality increase and the development of standards analogous to the I-PASS signout format for end-of-rotation handoffs.

Lehmann CU, Sroussi B, Jaulent MC, eds. Yearb Med Inform. 2016;1:1-271.

… eds. Yearb Med Inform. 2016;1:1-271. … Hullin Lucay Cossio C; Di Iorio CT; de Lusignan S; de Keizer N; … M. … J. … M. … FM … E. … JW … Y. … S. … J. … S. … E. … C. … R. … R. … K. … Y. … … … Symonds … Barros … Couto … Borycki … Dexheimer … Gong … Jensen … Kaipio … Kennebeck … Kirkendall … Kuziemsky … …
Levinson W, Yeung J, Ginsburg S. JAMA. 2016;316:764-5.
Disclosing medical errors to patients is essential for maintaining a therapeutic relationship and preventing further harm. This commentary describes a case in which a physician inadvertently used nonsterile instruments to perform procedures on two patients and presents options for what the physician might do next. Recommended best practices for error disclosure include being honest about what happened, explicitly stating that an error occurred, and explaining to the patient any relevant specific information that might be helpful in terms of necessary follow-up. The authors suggest that all errors be formally reviewed to prevent future harm and that health care systems should create an environment that facilitates error reporting.
Barwise A, Thongprayoon C, Gajic O, et al. Crit Care Med. 2016;44:54-63.
Despite widespread implementation of rapid response systems, they remain controversial. This study showed that delayed activation of rapid response was associated with worse morbidity and higher mortality compared to timely rapid response implementation. This work adds to recent data suggesting that rapid response improves patient safety.
Guenter P, Jensen G, Patel V, et al. Jt Comm J Qual Patient Saf. 2015;41:469-473.
Previous studies have explored safety issues related to parenteral nutrition processes, but problems associated with general nutrition for inpatients have received scant attention. This commentary advocates for promoting awareness around malnutrition as a hospital-acquired condition and outlines 12 actions to improve the safety of nutrition care for hospitalized patients, including use of routine assessments and checklists.
Hovde B, Jensen KH, Alexander GL, et al. West J Nurs Res. 2015;37:877-98.
Clinician use of clinical guidelines is known to be less than optimal. According to this review, evidence indicates that nurse utilization of computerized clinical guidelines resulted in care process improvements, but further research is needed to determine if there is a correlation between increased provider access to guidance and patient safety.
Andersen HB, Lipczak H, Borch-Johnsen K, eds. Cogn Technol Work. 2015;17:1-155.
… CHM … HB … H. … K. … M. … S. … DN … I. … K. … M. … M. … C. … H. … MM … JL … P. … H. … B. … AS … S. … O. … D. … P. … LF … J. … RL … WB … F. … P. … N. … ML … FM … GB … K. … M. … T. … J. … … … Dyrstad … Testad … Aase … Storm … Sandager … Sperling … Jensen … Vinter … Knudsen … Doupi … Svaar … Bjørn … Haugen … …
Fox ER, Sweet B, Jensen V. Mayo Clin Proc. 2014;89:361-73.
National drug shortages in the United States have become a serious patient safety concern. Spotlighting the impact of drug shortages on the economy and health care, this review reveals underlying issues contributing to the problem and highlights the persisting need for solutions to address them.
Moriarty JP, Schiebel NE, Johnson MG, et al. Int J Qual Health Care. 2014;26:49-57.
Although effectiveness of rapid response teams has traditionally been measured by using rates of cardiac arrests or intensive care unit transfers, this study advocates for using the AHRQ failure to rescue metric instead. Failure to rescue rates declined in the second year after implementation of the rapid response team in concert with increased utilization of the team.

Randell E, Schneider W, eds. Clin Biochem. 2013;46:1159-1194.  

…   … W. … W. … J. … N. … N. … M. … L. … M. … J. … ML … SF … SS … J. … N. … DM … LC … MA … Randell … Schneider … Kalra … Kalra … Baniak … … … Sciacovelli … Marinova … Marcuccitti … Chiozza … Green … Raab … Swain … Smith … Grzbicki … Allen … Noble … W. Randell …