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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 264 Results
Edlow JA, Pronovost PJ. JAMA. 2023;329:631-632.
Medical errors should be examined in the context of system failure to generate lasting opportunities for learning and improvement. This commentary discusses the AHRQ 2022 report entitled Diagnostic Errors in the Emergency Department: a Systematic Review and suggests a focus on care delivery processes over individuals, definitions, error rate review, and system design as noteworthy approaches to error reduction.
Dixon-Woods M, Aveling EL, Campbell A, et al. J Health Serv Res Policy. 2022;27:88-95.
A key aspect of patient safety culture is the perception that all team members should speak up about safety concerns. In this study of 165 frontline and senior leader participants, deciding to report a safety event (referred to as a “voiceable concern”) is influenced by four factors: certainty that something is wrong and is an occasion for voice; system versus conduct concerns, forgivability, and normalization. Organizational culture and context effect whether an incident is considered a voiceable concern.
Gleason KT, Commodore-Mensah Y, Wu AW, et al. Nurse Educ Today. 2021;104:104984.
Massive online open courses (MOOCs) have the ability to reach a broad audience of learners. The Science of Safety in Healthcare MOOC was delivered in 2013 and 2014. At completion of the course, participants reported increased confidence on all six measured domains (teamwork, communication, managing risk, human environment, recognizing and responding, and culture). At 6 months post-completion, the majority agreed the content was useful and positively influenced their clinical practice, demonstrating that MOOCs are an effective interprofessional learning format.
Ibrahim SA, Pronovost PJ. JAMA Health Forum. 2021;2:e212430.
Artificial intelligence (AI) and big data have potential to impact health care improvement in a variety of ways. This commentary examines the intersection of AI, diagnosis, and inequality. The authors highlight several innovations that could reduce health disparities and diagnostic errors in at-risk patient populations if adopted.
Morris AH, Stagg B, Lanspa M, et al. J Am Med Inform Assoc. 2021;28:1330-1344.
Clinical decision support systems are designed to improve clinical decision-making. The authors of this commentary suggest an alternative, eActions, to reduce clinician burden and increase replicability. Dissemination and use of eActions could contribute to improved clinical care quality and research.
Wu AW, Vincent CA, Shapiro DW, et al. J Patient Saf Risk Manag. 2021;26:93-96.
J Patient Saf Risk Manag … The July effect is a phenomenon … active, independent practice . The authors discuss how a systemic approach is required to situate these …
Mahadevan K, Cowan E, Kalsi N, et al. Open Heart. 2020;7.
Distractions and interruptions are common during delivery of health care. In this evaluation of 194 cardiac catheterization procedures at a single hospital, the authors found that fewer than half of all procedures were completed without interruption or distraction. The authors propose several actions such as the use of a ‘sterile cockpit’ to reduce distractions and improve patient safety.
Austin JM, Weeks K, Pronovost PJ. Jt Comm J Qual Patient Saf. 2020;47:265-267.
… Jt Comm J Qual Patient Saf … Prior research has identified racial … failures contributing to disparities, a commitment from health system leadership to address … care workers and leadership.   … Austin JM, Weeks K, Pronovost PJ. Health system leaders' role in addressing …
Dixon-Woods M, Campbell A, Martin G, et al. Acad Med. 2019;94:579-585.
Disruptive and unprofessional behaviors are known threats to safety culture and contribute to burnout among health professionals. In response to an episode of serious misconduct by a clinician, an academic hospital implemented a structured effort to address disruptive behavior by developing mechanisms for frontline staff to voice their concerns. This article reports on the development and implementation of the effort, which focused on addressing longstanding aspects of institutional culture that were perceived as tolerating—and providing tacit endorsement of—prominent leaders who engaged in disruptive behavior.
Dietz AS, Salas E, Pronovost P, et al. Crit Care Med. 2018;46:1898-1905.
This study aimed to validate a behavioral marker as a measure of teamwork, specifically in the intensive care unit setting. Researchers found that it was difficult to establish interrater reliability for teamwork when observing behaviors and conclude that assessment of teamwork remains complex in the context of patient safety research.
Hensley NB, Koch CG, Pronovost P, et al. Jt Comm J Qual Patient Saf. 2019;45:190-198.
… Jt Comm J Qual Patient Saf … Jt Comm J Qual Patient Saf … Following a sentinel wrong-patient event , a multidisciplinary quality … via the electronic health record. … Hensley NB, Koch CG, Pronovost PJ, et al. Wrong-Patient Blood Transfusion Error: …
Pronovost P, Johns MME, Palmer S, et al, eds. Washington, DC: National Academy of Medicine; 2018. ISBN: 9781947103122.
Although health information technology was implemented to improve safety, it has resulted in unintended consequences such as clinician burnout and perpetuation of incorrect information. This publication explores the barriers to achieving the interoperability needed to build a robust digital infrastructure that will seamlessly and reliably share information across the complex system of health care. The report advocates for adjusting purchasing behaviors to focus less on the price and features of each product and to instead look for interoperable technologies. The report outlines five action priorities to guide leadership decision-making around procurement, including championing systemwide interoperability and identifying goals and requirements. A PSNet interview discussed potential consequences of the digitization of health care.
Day RM, Demski RJ, Pronovost PJ, et al. J Patient Saf Risk Manag. 2018;23:155-166.
J Patient Saf Risk Manag … High reliability principles guide … complex environments. This commentary describes one system's organizational approach to fully cement improvement into … needed to sustain results. … Day RM; Demski RJ; Pronovost PJ; Sutcliffe KM; Kasda EM; Maragakis LL; Paine L; …
Padula WV, Black JM, Davidson PM, et al. J Patient Saf. 2020;16:e97-e102.
The Centers for Medicare and Medicaid Services (CMS) first implemented a policy of nonpayment for specific hospital-acquired conditions (HACs) in 2008. In 2014, they implemented a value-based purchasing program (the Hospital-Acquired Condition Reduction Program) that reduces reimbursement to hospitals with elevated rates of a range of HACs. The program measures HAC rates by a composite Patient Safety Indicator (PSI90), which includes 10 specific PSIs. This study examined HAC rates after implementation of the reimbursement penalty program at a cohort of academic medical centers. Overall, HAC rates declined over the 2 years following implementation of the program, with only rates of pressure ulcers increasing. Another recent study also found declines in HAC rates associated with CMS nonpayment initiatives, and data from AHRQ has also demonstrated significant reductions in HACs over the past 5 years. Nevertheless, concerns persist about the validity of using PSI for patient safety measurement over time, and other studies have found no effect of reimbursement policies on other HACs that are not included in PSI90 (such as specific health care–associated infections). A past PSNet perspective discussed the effect of pay-for-performance and other financial incentives for patient safety.

McDaniel SH, Salas E, eds. Am Psychol. 2018;73:305-600.

Effective teams are core to safe practice in a wide range of work environments. This special issue explores team psychology with an emphasis on high-risk industries such as space exploration, military operations, and health care. Articles cover topics such as the foundations of teamwork, factors that establish effective teams, and how context shapes team development.
Mathews SC, Sutcliffe K, Garrett MR, et al. J Healthc Risk Manag. 2018;38:38-46.
The patient safety community continues to struggle with implementation and sustainability of improvement programs. This commentary describes how one academic medical center used assessment tools to monitor, measure, and improve safety at the patient, provider, unit, and system levels in the organization.