Skip to main content

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.

Search All Content

Search Tips
Filter By Author(s)
Advanced Filtering Mode
Date Ranges
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Additional Filters
Approach to Improving Safety
Displaying 1 - 20 of 58 Results
MohammadiGorji S, Joseph A, Mihandoust S, et al. HERD. 2023;Epub Aug 8.
Well-designed workspaces minimize disruptions and distractions. This review and study describes several important ways to improve the anesthesia workspace in the operating room. Recommendations include demarcating an anesthesia zone with adequate space for equipment and storage and that restricts unnecessary staff travel into and through the zone. Each recommendation includes an illustrative diagram, explains its importance, and offers methods to achieve it.

Abraham J, Rosen M, Greilich PE eds. Jt Comm J Qual Patient Saf. 2023;49(8):341-434.

Handoffs occur several times during a surgical procedure, increasing the risk of communication mistakes and misunderstandings. This special issue explores perioperative handoffs and strategies to improve them. Topics covered include information accuracy, teamwork science, and artificial intelligence.
Suclupe S, Kitchin J, Sivalingam R, et al. J Patient Saf. 2023;19:117-127.
Patient identification mistakes can have serious consequences. Using the Systems Engineering for Patient Safety (SEIPS) framework, this qualitative study explored systems factors contributing to patient identification errors during intrahospital transfers. The authors found that patient identification was not completed according to hospital policy during any of the 60 observed patient transfer handoffs. Miscommunication and lack of key patient information were common factors contributing to identification errors.
Sutton E, Booth L, Ibrahim M, et al. Qual Health Res. 2022;32:2078-2089.
Patient engagement and encouragement to speak up about their care can promote patient safety. This qualitative study explored patients’ psychosocial experiences after surviving abdominal surgery complications. Findings highlight an overarching theme of vulnerability and how power imbalances between patients and healthcare professionals can influence speaking up behaviors.
Lusk C, Catchpole K, Neyens DM, et al. Appl Ergon. 2022;104:103831.
Tall Man lettering and color-coding of medication syringes provide visual cues to decrease medication ordering and administration errors. In this study, an icon was added to the standard medication label; participants were asked to identify four medications, with and without the icon, from pre-defined distances. Participants correctly identified the medications with icons slightly more often.
Bernstein SL, Catchpole K, Kelechi TJ, et al. Jt Comm J Qual Patient Saf. 2022;48:309-318.
Maternal morbidity and mortality continues to be a significant patient safety problem. This mixed-methods study identified system-level factors affecting registered nurses during care of people in labor experiencing clinical deterioration. Task overload, missing or inadequate tools and technology, and a crowded physical environment were all identified as performance obstacles. Improving nurse workload and involving nurses in the redesign of tools and technology could provide a meaningful way to reduce maternal morbidity.
Sujan M, Bilbro N, Ross A, et al. Appl Ergon. 2022;98:103608.
Failure to rescue refers to delayed or missed recognition of a potentially fatal complication that results in a patient’s death. This single-center study sought to more effectively manage deteriorating patients after emergency surgery and reduce failure to rescue rates. Researchers used the functional resonance analysis method (FRAM) to develop recommendations for strengthening organizational resilience. Recommendations included improving team communication, organizational learning, and relationships.
Fontil V, Pacca L, Bellows BK, et al. JAMA Cardiol. 2022;7:204-212.
Racial and ethnic inequities are increasingly being linked to health disparities. This study of more than 16,000 patients explored the association between race and ethnicity and blood pressure control. Findings suggest racial and ethnic inequities in treatment intensification may be associated with more than 20% of observed racial or ethnic disparities in blood pressure control.
Bernstein SL, Kelechi TJ, Catchpole K, et al. Worldviews Evid Based Nurs. 2021;18:352-360.
Failure to rescue, the delayed or missed recognition of a potentially fatal complication that results in the patient’s death, is particularly tragic in obstetric care. Using the Systems Engineering Initiative for Patient Safety (SEIPS) framework, the authors describe the work system, process, and outcomes related to failure to rescue, and develop intervention theories.
Vasey B, Ursprung S, Beddoe B, et al. JAMA Netw Open. 2021;4:e211276.
This study explored the role of machine-learning based clinical decision support (CDS) algorithms to support (rather than replace) human decision-making and the impact on diagnostic performance. This systematic review of 37 studies found limited evidence that the use of machine learning-based CDS systems contributes to improved diagnostic performance among clinicians. Interobserver agreement, user feedback, and clinician override were the most commonly reported outcomes. The authors emphasize the importance of further evaluation of human-computer interaction.

Auerbach AD, Bates DW, Rao JK, et al, eds. Ann Intern Med. 2020;172(11_Supp):S69-S144.

Research and error reporting are important strategies to uncover problems in health system performance. This special issue highlights vendor transparency and context as important areas of focus to ensure electronic health records (EHR) research and reporting help improve system reliability. The articles cover topics such as a framework for research reporting, design of randomized controlled trials for technology studies, and designing research on patient portal enhancement.
Koch A, Burns J, Catchpole K, et al. BMJ Qual Saf. 2020;29:1033-1045.
This systematic review evaluated the relationships between intraoperative flow disruptions (eg, interruptions, equipment malfunctions, unexpected patient conditions) and provider, surgical process, and patient outcomes. On average, 20.5% of operating time was attributed to flow disruptions and these disruptions were either negatively or not substantially associated with surgical outcomes. The authors observed substantial heterogeneity of the evidence base and provided recommendations for future research on the effects of flow disruptions in surgery.
Sondheim SE, Mattie A, Vigil J, et al. J Healthc Risk Manag. 2020;40:18-24.
Using publicly-available data in Connecticut, this study analyzed the comparability of four health care rating agencies in the United States (Leapfrog, CMS, Heathgrades, and Why Not the Best [WNTB]). The only significant correlations were between Leapfrog and CMS and Leapfrog and WNTB, but the correlation between Leapfrog and CMS is likely due to Leapfrog’s use of CMS data in their algorithm. The lack of correlation between the ratings of these four agencies may lead to consumer confusion about publicly-reported patient safety data.
Yamada NK, Catchpole K, Salas E. Semin Perinatol. 2019;43:151174.
Human factors are frequently an important contributing factor to patient safety events. This review describes the role of human factors in patient safety and presents three case studies of human factors affecting care in the NICU. A PSNet Human Factors Primer on human factors expands on these concepts.

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

… Appl Ergon . 2019;78:248-308. … RIPCHD.OR Study Group … K. … A. … MS … M. … R. … M. … JT … T. … PT … TS … TR … A. … … … EA … RJ … RC … V. … BR … AM … CA … AO … AL … J. … DM … S. … A. … K. … K. … A. … D. … J. … AA … DJ … M. … J. … B. … R. … N. … K. … EJ … M. … MT … JC … LW … Catchpole … Bisantz … Hallbeck … Weigl … Randell … Kossack … …
Morgan L, Benson D, McCulloch P. BMJ. 2019;364:l1037.
Investigations into medical mistakes that result in patient harm should be fair, complete, and consider the context of the event. This commentary examines investigation processes in the United Kingdom and highlights the importance of understanding how human factors contribute to error to help effectively assess each incident and support transparency and improvement.
Davis SS, Babidge WJ, McCulloch GAJ, et al. ANZ J Surg. 2019;89:764-768.
… ANZ J Surg … ANZ J Surg … Clinical decision-making is a complex process affected by many factors and has important … and New Zealand Audit of Surgical Mortality database over a 1-year period, researchers fully audited 3422 deaths and identified 226 cases involving a clinical decision-making incident (CDMI) thought to be …