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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 26 Results
Rabbani N, Pageler NM, Hoffman JM, et al. Appl Clin Inform. 2023;14:521-527.
Implementation of or upgrades to new electronic health records (EHR) is a complex process which sometimes results in unforeseen negative consequences. This study examines hospital-acquired conditions (HACs) and care bundle compliance rates at 27 pediatric hospitals before, during, and after implementation or upgrade of EHR systems. Contrary to previous studies, no significant differences were found in either HAC or bundle compliance rates.
Winning AM, Merandi J, Rausch JR, et al. J Patient Saf. 2021;17:531-540.
Healthcare professionals involved in a medical error often experience psychological distress. This article describes the validation of a revised version of the Second Victim Experience and Support Tool (SVEST-R), which was expanded to include measures of resilience and desired forms of support.
Blazin LJ, Sitthi-Amorn J, Hoffman JM, et al. Pediatr Qual Saf. 2020;5:e323.
This article describes one pediatric hospital’s experience adapting and implementing the I-PASS handoff program for inpatient nursing bedside report, physician handoff, and imaging/procedures handoff.  The project demonstrates that I-PASS can be successfully used across a hospital system in various settings to reduce handoff-related errors.  
Hoffman JM, Keeling NJ, Forrest CB, et al. Pediatrics. 2019;143.
This study aimed to prioritize research topics in pediatric patient safety. Parents and safety leaders completed an online survey that informed a stakeholder panel process. Key areas of interest included high reliability, safety culture, detection of deterioration, sepsis, diagnosis, medication safety, and ambulatory patient safety.
Rodriquez J, Scott SD. Jt Comm J Qual Patient Saf. 2018;44:137-145.
Clinicians who experience emotional distress after adverse events or medical errors are referred to as second victims. Researchers surveyed health care providers whose career choices were impacted by involvement in an adverse event. In keeping with prior research, respondents reported a lack of support after the event.
Wu AW, Shapiro J, Harrison R, et al. J Patient Saf. 2020;16:65-72.
Word choice can impact buy-in for programs and integrating concepts across an organization. This review examines the term "second victim" as a label for health professionals involved in adverse events. The authors explore both constructive and negative reactions to the term and suggest that context and culture affect the appropriateness of its use.
Mira JJ, Lorenzo S, Carrillo I, et al. Int J Qual Health Care. 2017;29:450-460.
This review study examined policies to address the consequences of adverse events for patients, providers, and organizations. The methods included focus groups and a literature review. The team generated recommendations such as involving patients in event investigation, providing time away from usual work for second victims, and establishing a crisis plan for organizations.
Merandi J, Liao NN, Lewe D, et al. Pediatr Qual Saf. 2019;2:e031.
This study reports on the implementation of a second victim support program for staff at a pediatric hospital. Building on a previously described model, the institution developed a system to provide support for staff involved in errors. Over a 2-year period, more than 200 staff received support and survey responses indicated that employees found the program to be beneficial.
Burlison JD, Quillivan RR, Scott SD, et al. J Patient Saf. 2021;17:195-199.
Health care organizations are increasingly recognizing the importance of providing support to second victims. In this survey study, researchers found that when respondents perceived their organization as supportive to second victim distress, they were less likely to express a desire to leave their job or to require time away from work. The authors point out that this is the first study to look at the impact of the second victim experience on work-related outcomes.
Burlison JD, Quillivan RR, Kath LM, et al. J Patient Saf. 2020;16:187-193.
Hospitals often rely on voluntary patient safety event reporting systems to identify safety issues. However, significant barriers to reporting exist and most systems capture only a fraction of adverse events. In this study, researchers analyzed data from the AHRQ Hospital Survey of Patient Safety Culture to better understand what aspects of safety culture might affect event reporting. They found that multiple dimensions of safety culture, including feedback about error, were positively correlated with an increased frequency of events reported. To augment voluntary reporting, the authors recommend that institutions focus on providing feedback to reporters and communicate the resultant improvement efforts. A previous PSNet perspective highlighted the importance of providing feedback with regard to incident reporting.
Quillivan RR, Burlison JD, Browne EK, et al. Jt Comm J Qual Patient Saf. 2016;42:377-386.
The second victim phenomenon describes the distress health care providers can experience after adverse events. This survey of 358 nurses at a single pediatric hospital found that those working in a stronger safety culture were less likely to report distress after involvement in a patient safety event. The authors suggest that bolstering safety culture can help prevent negative effects of second victim experiences.
Scott SD, McCoig MM. J Healthc Risk Manag. 2016;35:6-13.
Health care workers who experience emotional consequences after being involved in a medical error are known as second victims. This commentary reviews the stages of recovery that such health care workers experience, determined by a hospital-based program to provide immediate support for second victims. A PSNet perspective offers insights from one of the authors about this program.
Goldspiel B, Hoffman JM, Griffith NL, et al. Am J Health Syst Pharm. 2015;72:e6-e35.
The American Society of Health-Systems Pharmacists developed these guidelines to apply medication safety best practices to the delivery of chemotherapy and biotherapy agents. These recommendations include sets of specific actions for the overall health care system and for frontline providers.
Burlison JD, Scott SD, Browne EK, et al. J Patient Saf. 2017;13:93-102.
The second victim phenomenon—the damaging psychological impacts of errors on the clinicians who are involved—has been well documented in the literature. This study presents the development and validation of a survey tool, the SVEST, to examine clinicians' experiences with errors and evaluate the effectiveness of approaches to aid second victims.
Call RJ, Burlison JD, Robertson JJ, et al. J Pediatr. 2014;165:447-52.e4.
To investigate the utility of a trigger tool in detecting adverse drug events (ADEs) in pediatric hematology and oncology patients, this study compared the tool with a voluntary reporting system. Implementation of the trigger tool led to inclusion of many cases that were not ADEs (false positives). In contrast, voluntary reporting did not identify all ADEs that were found using the trigger tool, implying under-reporting. These results reinforce prior research suggesting that multiple detection methods are needed to comprehensively detect ADEs. The authors advocate for triggers to be refined according to patient population and hospital setting to augment their usefulness. A previous AHRQ WebM&M perspective discusses the role of trigger tools in identifying ADEs and measuring patient safety.
Petschonek S, Burlison JD, Cross C, et al. J Patient Saf. 2013;9:190-7.
The importance of safety culture in medicine is well recognized and health care institutions now regularly administer validated measurement tools such as AHRQ's Patient Safety Culture Survey. Although early safety culture efforts focused on shifting from a punitive approach to a systems-based strategy to reduce medical errors, growing support has emerged for the establishment of a just culture that balances no-blame with appropriate accountability. This study sought to develop a survey that would measure individual perceptions of just culture in a hospital setting. The research team created a 27-item survey, which displayed adequate theoretical structure and internal reliability. This instrument now needs to be validated in other settings and among broader populations.
McBride A, Holle LM, Westendorf C, et al. Am J Health Syst Pharm. 2013;70:609-17.
National drug shortages in the United States have become a serious patient safety concern. These shortages reached record levels in 2011, resulting in documented patient harm, longer stays, and increased costs. This survey of US oncology pharmacists reveals that cancer drug shortages were common during the first half of 2011 and resulted in delays and changes in chemotherapy. Use of less familiar alternatives also led to increased risk of medication errors and adverse outcomes. Near misses were reported by 16% of respondents, and 6% documented medication errors. A previous article discussed how hospitals and health care leaders might address this "patient safety crisis."