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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 22 Results
Appelbaum NP, Santen SA, Perera RA, et al. J Patient Saf. 2022;18:370-375.
Residents and trainees frequently report experiencing bullying and disrespectful behaviors in the workplace. This study explored the relationship between resident psychological safety, perceived organizational support, and humiliation. Results indicate resident perception of increased organizational support (e.g., help is available when they have a problem) reduces the negative impact of humiliation on their psychological safety.
Mills PD, Watts BV, Hemphill RR. J Patient Saf. 2021;17:e423-e428.
Researchers reviewed 15 years of root cause analysis reports of all instances of suicide and suicide attempts on Veterans Health Administration (VHA) grounds. Forty-seven suicides or suicide attempts were identified, and primary root causes included communication breakdown and a need for improved suicide interventions. The paper includes recommended actions to address the root causes of attempted and completed patient suicides.
Feeser VR, Jackson AK, Savage NM, et al. Ann Emerg Med. 2021;77:449-458.
This study characterized patient safety event report submissions over a six-month period at one university health system and found that one-quarter of reports were punitive. Compared to nonpunitive reports, punitive reports were more likely to focus on communication and employee behavior issues, policies/procedures, and staff training or competency issues. Punitive reports commonly involved adverse reactions or complications and communication errors.  
Soncrant C, Mills PD, Neily J, et al. J Patient Saf. 2020;16:41-46.
In this retrospective review of root cause analysis (RCA) reports of select gastrointestinal procedures, researchers identified 27 adverse events 30-month period. Nearly half (48%) of events caused major or catastrophic harm. The most frequently reported adverse events were attributable to human factors (22%), medication errors (22%) or retained items; retained items were associated with the most harm.
Hagley GW, Mills PD, Shiner B, et al. Phys Ther. 2018;98:223-230.
This analysis of the Veterans Health Administration root cause analysis database identified adverse events that occurred during rehabilitation services, such as physical therapy, occupational therapy, or speech and language therapy. Rehabilitation-related adverse events were extremely rare. The most common incidents were falls and delayed response to clinical deterioration.
Soncrant CM, Warner LJ, Neily J, et al. AORN J. 2018;108:386-397.
Root cause analysis has been widely promoted as a failure analysis tool for use in a variety of settings. This quality improvement project applied the method to patient falls in Veterans Health Administration operating rooms and developed recommendations to guide improvement. Areas of focus included team communication, restraint use, and staff education. An Annual Perspective provides insights regarding how to enhance root cause analysis to help investigate incidents and improve care.
Schwartz ME, Welsh DE, Paull DE, et al. J Healthc Risk Manag. 2018;38:17-37.
Communication failures are known to contribute to medical errors. In the field of aviation, crew resource management is used to teach teamwork and effective communication. In this study, researchers evaluated the impact of a team training program developed by the Veterans Health Administration National Center for Patient Safety and modeled after crew resource management training. The Teamwork and Safety Climate Questionnaire was used to evaluate safety climate prior to and after the training. They found that scores on the 27-item survey increased on all questions from baseline to 1 year and conclude that this type of team training improves patient safety by enhancing teamwork and ensuring effective communication among clinicians. A PSNet perspective provides insights on team training.
Neily J, Silla ES, Sum-Ping S (J) T, et al. Anesth Analg. 2017;126:471-477.
This study examined root cause analyses performed by the Veterans Health Administration to identify and characterize anesthesia-related safety events. Although a relatively small number of events were found, the authors identified several human factors solutions that, if implemented, could prevent common types of errors.
Riblet N, Shiner B, Watts B, et al. J Nerv Ment Dis. 2017;205:436-442.
This review of root cause analysis reports about suicide within 7 days of discharge from inpatient mental health facilities determined that most cases of suicide occurred prior to scheduled outpatient postdischarge follow-up. Many patients who went on to die by suicide left against medical advice but did not meet criteria to be held against their wishes, highlighting the conflict between safety and patient autonomy.
Watts B, Paull DE, Williams LC, et al. Am J Med Qual. 2016;31:598-600.
Integrating system safety and quality improvement concepts into existing curriculum has been advocated as a strategy to prepare resident physicians for safety improvement work. This commentary describes a Veterans Affairs program to incorporate safety leadership and educational skills into graduate medical education.
Paull DE, Mazzia L, Neily J, et al. Am J Surg. 2015;210:6-13.
This analysis of the Veterans Health Administration root cause analysis database found that wrong surgery events can occur despite adherence to the Universal Protocol, due to errors preceding and following the protocol's use. The authors suggest that additional processes initialized earlier and continuing later through the surgical process are required to fully prevent these events.
Miller K, Mims M, Paull DE, et al. JAMA Surg. 2014;149:774-9.
Wrong-site procedures result in significant patient harm, and prior studies have shown that—contrary to traditional assumptions—many of these errors occur outside the operating room. This analysis of 14 cases of wrong-site thoracenteses, a procedure to remove fluid from around the lung, identified several common themes in these errors. The majority of errors resulted in serious patient injury. Root cause analysis of the errors found that clinicians often failed to perform a time out and did not correctly document laterality in consent forms and clinical records. A case of a wrong-side thoracentesis that resulted in the death of a patient is discussed in a previous AHRQ WebM&M commentary.
Lee A, Mills PD, Neily J, et al. Jt Comm J Qual Patient Saf. 2014;40:253-62.
This chart review study analyzed information from the Veterans Health Administration national database of root cause analyses to describe adverse events among veterans aged 65 years and older that resulted in sustained injury or death. Frequent incidents were falls, delays in diagnosis or treatment, and medication errors. Inadequate communication was the most common root cause identified in adverse events, and within this category, poor communication among providers (such as handoffs) often resulted in adverse events. Although virtually all root cause analyses led to implementation of action plans, only 40% were deemed effective. Compared to previous research, this study highlights robust use of root cause analysis while emphasizing the need for ongoing monitoring and improvement of corrective actions.
West P, Neily J, Warner L, et al. Jt Comm J Qual Patient Saf. 2014;40:235-239.
This study surveyed nurse managers to evaluate the implementation of pre-surgical briefings and post-surgical debriefings recommended by the World Health Organization's Safe Surgery program. Researchers found that practices were variably sustained and team training appeared to augment implementation.
Mills PD, Watts V, Hemphill RR. J Hosp Med. 2014;9:182-5.
A suicide attempt by a hospitalized patient is considered a never event. The majority of inpatient suicides occur in psychiatric units, but a prior Joint Commission sentinel event alert suggested that nearly 15% of attempts happen on medical wards. This study reviewed root cause analysis reports of suicide attempts on medical units in the Veterans Health Administration between 1999 and 2012. Fifty cases were identified and five represented completed suicides. Alcohol withdrawal was the most common reason for admission among patients who attempted suicide while hospitalized. The case reviews revealed communication failures, such as lack of discussion about suicide risks or mitigation plans during handoffs to other medical providers, as common contributors to these events. The authors recommend improved staff education, standardized communication for suicide risk, and protocols for appropriate management of suicidal patients. A prior article provided further implementation strategies for avoiding inpatient suicides.
WebM&M Case September 1, 2013
… information regarding a patient's past medical history. … Robin R. Hemphill, MD, MPH … Chief Safety and Risk Awareness Officer, …
Giardina TD, King BJ, Ignaczak AP, et al. Health Aff (Millwood). 2013;32:1368-75.
Failure to properly follow up on test results can result in missed or delayed diagnoses. This study from the Veterans Affairs (VA) system reveals the clinical impact of inadequate care processes for patients with urgent follow-up needs. By analyzing 111 root cause analyses of diagnostic error cases in the outpatient setting, the authors determined that poorly coordinated care—arising from a lack of systems to track patients needing urgent evaluation, insufficient follow-up of abnormal test results, and inadequate communication between clinicians—contributed to most of the missed or delayed diagnoses. Although electronic medical records (EMRs) should facilitate responding to abnormal test results, prior VA studies have shown that a small but clinically significant proportion of abnormal laboratory tests and radiology studies are not acted upon in a timely fashion (despite the VA having a fully integrated EMR for more than a decade). The authors advocate for refining EMR systems to better facilitate communication between clinicians and for emphasizing teamwork training in the outpatient setting.