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 68 Results
Madigan C, Way KA, Johnstone K, et al. J Safety Res. 2022;81:203-215.
Leadership engagement in safety is essential to implementing sustainable change. This qualitative study found that rational persuasion and legitimating were the most frequently used and certain factors – such as organizational culture, safety beliefs, and leadership style – can impact how safety professionals influence managers making safety decisions in healthcare settings. The authors discuss the importance of both technical and non-technical skills to enhance influence among safety professionals.
Hallvik SE, El Ibrahimi S, Johnston K, et al. Pain. 2022;163:83-90.
Opiates are a high-risk medication due to the potential for adverse events including misuse and overdose. This study examined whether dose reduction or discontinuation after high-dose chronic opioid therapy is associated with suicide, overdose, or other adverse events. In this cohort of Oregon Medicaid recipients, discontinuation increased the risk for suicide or opioid-related adverse events. Patients with stable or increasing doses had an increased risk of overdose.
Theobald KA, Tutticci N, Ramsbotham J, et al. Nurse Educ Pract. 2021;57:103220.
Simulation training is often used to develop clinical and nontechnical skills as part of nursing education.  This systematic review found that repeated simulation exposures can lead to gains in clinical reasoning and critical thinking. Two emerging concepts – situation awareness and teamwork – can enhance clinical reasoning within simulation. With more nursing schools turning to simulation to replace clinical site placement, which is in short supply, understanding of simulation in training is critical.
Raghuram N, Alodan K, Bartels U, et al. Virchows Archiv. 2021;478:1179-1185.
Autopsies are an important tool for identifying diagnostic errors. This retrospective study of 821 pediatric cancer deaths found that 10% had a major diagnostic discrepancy between antemortem and postmortem diagnoses. These discrepancies primarily consisted of missed infections, missed cancer diagnoses, and organ complications.
Stall NM, Johnstone J, McGeer AJ, et al. J Am Med Dir Assoc. 2020;21:1365-1370.e7.
In response to the COVID-19 pandemic, nursing homes limited access to visitors and family caregivers in order to limit virus transmission. Based on existing nursing home visitor policies, the authors developed data-driven, expert-reviewed guidance for re-opening Canadian nursing homes to family caregivers and visitors.

Durning S, Holmboe E, Graber ML, eds. Diagnosis(Berl). 2020;7(3):151-344.

Challenges to effective clinical reasoning reduce diagnostic accuracy. This special issue provides background for a new approach to clinical reasoning: situativity. The articles explore the four complementary facets of the concept -- situated cognition; distributed cognition; embodied cognition; and ecological psychology – and describes how situativity can enhance diagnosis through a holistic approach to education, assessment, and research.    

Jt Comm J Qual Saf. 2020;46(7):PI-II:2020;371-399.

The Eisenberg Awards honor individuals and organizations who have had noteworthy impacts on patient safety and quality improvement. This article collection highlights the work of the 2019 honorees: Gordon D. Schiff, MD; WellSpan Health, York, Pennsylvania; and HCA Healthcare, Nashville, Tennessee.
Petersen EE, Davis NL, Goodman D, et al. MMWR Morb Mortal Wkly Rep. 2019;68:423-429.
Maternal safety is a critical concern in health care, and prior studies have discussed racial and ethnic disparities in patient safety. The Centers for Disease Control and Prevention examined trends in pregnancy-related deaths between 2011 and 2015. This analysis found that black women had rates of maternal mortality 3.5 times that of white women; Native American/Alaska Native women had rates 2.5 times higher than white women. About 60% of deaths were deemed preventable, and leading causes included cardiovascular events such as venous thromboembolism, infection, and hemorrhage. The study team recommends implementing interventions at health system, provider, community, and patient levels to prevent maternal mortality. A recent Annual Perspective on maternal safety touched on the persistently higher death rates among black women and discussed national initiatives to improve outcomes in maternity care.
Johnston BE, Lou-Meda R, Mendez S, et al. BMJ Glob Health. 2019;4.
Medical errors are a concern across the economic spectrum worldwide. This commentary describes an educational effort to develop champions to lead patient safety, quality improvement, and infection control initiatives in health systems in low- and middle-income countries. The authors highlight the importance of contextualizing training to consider local needs and resources.
Hemsley B, Steel J, Worrall L, et al. J Safety Res. 2019;68:89-105.
This systematic review of falls among individuals with speech, language, and voice disability found that these populations are often excluded from studies of falls. However, there is some evidence that communication disability leads to increased risk of falls and the authors call for further study for this population.
Munoz-Price S, Bowdle A, Johnston L, et al. Infect Control Hosp Epidemiol. 2018:1-17.
This expert guidance provides recommendations to help health care facilities develop policies for preventing health care–associated infections in the operating room. The authors build on existing anesthesia safety practices to outline specific actions for infection prevention and control.
Cardiello R, Johnston S, Kiely S. J Healthc Risk Manag. 2019;38:24-31.
Patient safety hotlines are an established method for clinicians and patients to report safety concerns. This commentary describes how one organization implemented a hotline for patients to report concerns. The authors discuss their experiences in working with vendors and analysis of the program results to inform future work.
Hassen Y, Singh P, Pucher PH, et al. Surgery. 2018;163:1226-1233.
Safe surgical care requires attention to risks in the operating room and in the postoperative surgical ward. Investigators interviewed clinicians, nurses, patients, and administrators to determine the most vital components for a safe surgical ward, which included an adequate nursing skill mix and positive safety culture. A PSNet perspective described how surgical safety has evolved as a field.
Thorpe KE, Joski P, Johnston KJ. Health Aff (Millwood). 2018;37:662-669.
Infections with antibiotic-resistant organisms are increasingly common in hospitals and ambulatory care, primarily driven by overuse of antibiotics for treatment of nonbacterial illnesses. This economic analysis found that antibiotic-resistant infections have doubled in incidence since 2002, and they add approximately $1,400 to the cost of care for each patient with an antibiotic-resistant infection. The study was performed using data from the Medical Expenditure Panel Survey, which is conducted by AHRQ. This survey does not include data on institutionalized adults, such as residents of long-term care facilities. Since antibiotic-resistant infections are common in these patients, this study may actually underestimate the total economic burden of these infections. The devastating effects of an antibiotic-resistant infection for a health care practitioner were vividly illustrated in a PSNet perspective.
Huang GC, Kriegel G, Wheaton C, et al. BMJ Qual Saf. 2018;27:492-497.
Although improving diagnosis is a critical patient safety priority, few interventions have been tested, especially in outpatient settings. This pre–post study examined whether a "diagnostic pause," a type of checklist, could improve outpatient diagnostic safety. The team used an electronic health record–based automated trigger to identify patients at risk for missed diagnosis—patients presenting for an urgent care visit who had a previous urgent care visit within 2 weeks. At the second visit, the clinician received a prompt to reflect on the diagnosis and a short survey about how the prompt affected their actions. Participating clinicians responded to about 60% of the prompts they received and reported changing their actions 13% of the time. The authors conclude that identifying challenging diagnoses and supplementing clinicians' current diagnostic pathways requires further research.

Hignett S, Albolino S, Catchpole K, eds. Ergonomics. 2018;61:1-161.

… and frontline program implementation barriers . … Hignett S, Albolino S, Catchpole K, eds. Ergonomics. 2018;61:1-161. … Di Tommaso M … S. … G. … D. … M. … F. … I. … I. … G. … R. … T. … A. … S. … C. … E. … …

Benzon HT, Anderson TA, eds. Anesth Analg. 2017;125(5):1427-1778.

… Analg. 2017;125(5):1427-1778. … Brown RE Jr; Du Vivier D … A. … HA … TA … H. … B. … M. … DE … A. … M. … HT … PA … DJ … … JM … BT … J. … C. … E. … DJ … NB … SM … LR … K. … MA … S. … CL … CR … EY … P. … E. … JP … RD … JC … EM … SA … RJ … … MC … LK … ME … EC … BI … Zhu … Benzon … Anderson … Meng … Johnston … Englesakis … Moulin … Bhatia … Yaster … Benzon … …
Graber ML, Byrne C, Johnston D. Diagnosis (Berl). 2017;4:211-223.
Health information technologies (IT) are seen to facilitate diagnostic improvement. This review discusses opportunities and problems that health IT can bring to diagnostic safety. The authors recommend ways to safely use health IT to improve diagnosis.