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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 83 Results
Hibbert PD, Stewart S, Wiles LK, et al. Int J Qual Health Care. 2023;Epub Oct 17.
Quality improvement and patient safety initiatives require incredible human and financial resources, they so must be selected carefully to achieve the greatest return on investment. This article describes important considerations for hospital leaders when selecting and implementing initiatives. Safety culture, policies and procedures, supporting staff, and patient engagement were notable themes. The included "patient safety governance model" provides a framework to develop patient safety policy.
Seaman K, Meulenbroeks I, Nguyen A, et al. Int J Qual Health Care. 2023;35:mza080.
Patients in long-term or residential care facilities are at high risk of falls. In this study, researchers applied the International Classification for Patient Safety (ICPS) criteria to categorize types of falls occurring in residential aged care facilities in Australia. Falls requiring hospitalization more often occurred in residents’ bedrooms or communal areas. Resident pre-existing psychological or physical health were the most common contributing factor in falls that required a hospitalization.
Georgiou A, Li J, Thomas J, et al. Public Health Res Pract. 2023;33:e3332324.
Several systemic factors may hinder communication of test results to patients and clinicians. This article describes a research project in Australia, "Delivering safe and effective test result communication, management and follow-up." Along with previously identified test result communication challenges such as workflow and technology, this paper highlights the need for national thresholds for critical laboratory 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.
Nicklin W, Greenfield D. Int J Qual Health Care. 2023;35:mzad036.
Accreditation remains an important strategy for improving and maintaining high quality despite mixed patient outcomes. This commentary advocates for accrediting agencies to continue with previously-defined safety goals (i.e., not “lowering the bar” due to the impact of the COVID-19 pandemic) to ensure patients continue to receive excellent care and stakeholders maintain trust in the accreditation process.
Pavithra A, Mannion R, Sunderland N, et al. J Health Org Manag. 2022;36:245-271.
Speaking up behaviors among healthcare workers is indicative of psychological safety and a culture of safety. This survey of healthcare staff working at seven sites across one hospital network in Australia found that speaking up behaviors are influenced by whether staff feel empowered in their roles and supported by their peers and supervisors.
Westbrook JI, Li L, Raban MZ, et al. NPJ Digit Med. 2022;5:179.
Pediatric patients are particularly vulnerable to medication errors. This cluster randomized controlled trial examined the short- and long-term impacts of an electronic medication management (eMM) system implemented at one pediatric referral hospital in Australia. Findings suggest that eMM implementation did not reduce medication errors in the first 70 days of use, but researchers observed a decrease in medication errors one year after implementation, suggesting long-term benefits.
Westbrook JI, McMullan R, Urwin R, et al. Intern Med J. 2022;52:1821-1825.
The COVID-19 pandemic dramatically impacted team functioning in healthcare settings. This survey of nearly 1,600 clinical and non-clinical staff at five Australian hospitals did not identify any perceived increases in unprofessional behaviors during the pandemic and 44% of respondents cited improvements in teamwork.
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.
Mcmullan RD, Urwin R, Gates PJ, et al. Int J Qual Health Care. 2021;33:mzab068.
Distractions in the operating room are common and can lead to errors. This systematic review including 27 studies found that distractions, interruptions, and disruptions in the operating room are associated with a range of negative outcomes. These include longer operative duration, impaired team performance, self-reported errors by colleagues, surgical errors, surgical site infections, and fewer patient safety checks.
Kinlay M, Zheng WY, Burke R, et al. Res Social and Adm Pharm. 2021;17:1546-1552.
Computerized provider order entry (CPOE) systems have been advocated as a strategy to reduce medical errors, but some errors persist. This narrative review identified knowledge gaps in the relationship between CPOE systems and how systems-related errors change over time. Studies suggest that system-related errors persist with long-term use of CPOE systems, but future research should explore the types of errors that occur, when they occur, and the system factors contributing to the errors.
Gates PJ, Hardie R-A, Raban MZ, et al. J Am Med Inform Assoc. 2021;28:167-176.
Electronic prescribing systems (such as computerized provider order entry) can aid in medication reconciliation and prevent medication errors. In this systematic review, the authors found variable evidence about the effectiveness of these systems for medication error and harm reduction. Included studies reported reductions in error rates, but implementation of electronic systems did not result in less patient harm.
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.  
Thomas J, Dahm MR, Li J, et al. J Am Med Inform Assoc. 2020;27:1214–1224.
This qualitative study explored how clinicians ensure optimal management of diagnostic test results, a major patient safety concern. Thematic analyses identified strategies clinicians use to enhance test result management including paper-based manual processes, cognitive reminders, and adaptive use of electronic medical record functionality.  
Staines A, Amalberti R, Berwick DM, et al. Int J Qual Health Care. 2021;33:mzaa050.
The authors of this editorial propose a five-step strategy for patient safety and quality improvement staff to leverage their skills to support patients, staff, and organizations during the COVID-19 pandemic. It includes (1) strengthening the system and environment, (2) supporting patient, family and community engagement and empowerment, (3) improving clinical care through separation of workflows and development of clinical decision support, (4) reducing harm by proactively managing risk for patients with and without COVID-19, and (5) enhancing and expanding the learning system to develop resilience.