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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 62 Results
Naya K, Aikawa G, Ouchi A, et al. PLoS One. 2023;18:e0292108.
Healthcare workers who are involved in patient safety incidents and experience adverse psychological or emotional outcomes are often referred to as second victims. This systematic review and meta-analysis found that 58% of healthcare workers in intensive care unit (ICU) settings have experienced second victim outcomes, including guilt, anxiety, anger at oneself, and decreased self-confidence. The review also found that one in five individuals took longer than 12 months to recover or did not recover at all, underscoring the importance of organizational support programs for healthcare workers involved in patient safety incidents.
Anderson E, Mohr DC, Regenbogen I, et al. J Patient Saf. 2021;17:316-322.
Burnout and low staff morale have been associated with poor patient safety outcomes. This study focused on the association between organizational climate, burnout and morale, and the use of seclusion and restraints in inpatient psychiatric hospitals. The authors recommend that initiatives aimed at reducing restraints and seclusion in inpatient psychiatric facilities also include a component aimed at improving organizational climate and staff morale.
Natale JAE, Boehmer J, Blumberg DA, et al. J Interprof Care. 2020;34:682-686.
This article describes COVID-19-related surge planning in an academic medical center encompassing a children’s hospital. The article describes interdisciplinary and interprofessional teamwork to identify innovative approaches to COVID-19 response, and highlights the importance of leadership, broad inclusion, transparent decision-making and continuous communication.
Lagoo J, Berry WR, Henrich N, et al. Jt Comm J Qual Patient Saf. 2020;46:314-320.
… Jt Comm J Qual Patient Saf … As part of a quality improvement initiative to enhance surgical … 20 physicians to understand potential areas of risk when a physician begins working in an unfamiliar setting.   … little to no onboarding when starting to practice in a new setting, which can limit their ability to provide safe …
Urbach DR, Dimick JB, Haynes AB, et al. BMJ. 2019;366:l4700.
… BMJ (Clinical research ed.) … BMJ … Checklists are a popular yet controversial strategy for improving the safety … debate the weaknesses and strengths of checklists through a discussion of the evidence . …
Berry WR, Edmondson L, Gibbons LR, et al. Health Aff (Millwood). 2018;37:1779-1786.
This study in the Health Affairs patient safety theme issue examines the implementation of surgical safety checklists. Checklists have been shown to improve patient outcomes in randomized control trials, but implementation studies have not consistently demonstrated similar improvements. In this statewide initiative, implementation of the checklist varied significantly among sites. Factors associated with more successful implementation included greater leadership participation, frontline engagement, and more frequent activities for all involved groups, including surgeons, nurses, technicians, and administrators. Sites that invested more funding and time also saw greater checklist implementation. The authors conclude that hospitals that participated more did better. Past PSNet interviews with Lucian Leape and David Urbach discussed their perspectives on surgical safety checklists.

Health Aff (Millwood). 2018;37(11):1723-1908.

The Institute of Medicine report, To Err Is Human, marked the founding of the patient safety field. This special issue of Health Affairs, published 20 years after that report, highlights achievements and progress to date. One implementation study of evidence-based surgical safety checklists demonstrated that leadership involvement, intensive activities, and engagement of frontline staff are all critical to successful adoption of safety practices. Another study demonstrated that communication-and-resolution programs either decreased or did not affect malpractice costs, providing further support for implementing such programs. Experts describe the critical role of human factors engineering in patient safety and outline how to enhance the use of these methods. The concluding editorial by David Bates and Hardeep Singh points to progress in reducing hospital-acquired infections and improving medication safety in acute care settings and highlights remaining gaps in the areas of outpatient care, diagnostic errors, and electronic health record safety. In the related information, the Moore Foundation provides free access to five articles in this special issue.
Gawande A. New Yorker. November 12, 2018.
In this magazine article, Atul Gawande describes a range of frustrations physicians experience as digitization becomes more widespread in health care. He elaborates upon several elements of electronic health record use that can degrade care processes and create conditions for errors, such as burnout, lack of patient-centeredness, and alert fatigue.
Haas S, Gawande AA, Reynolds ME. JAMA. 2018;319:1765-1766.
Changes in organizational process and governance can create downstream conditions that result in failures. This commentary explored how system expansion affects safety. The authors highlight the need for leadership to use system data to plan for and manage the impact of the resultant infrastructure and patient population changes on care delivery.
Lagoo J, Berry WR, Miller K, et al. Ann Surg. 2019;270:84-90.
… 360-degree reviews, in which team members evaluate a range of professional attributes and behaviors, were … informing others, and considering others' suggestions had a significantly higher risk for malpractice claims. Surgeons … surgeons could mitigate malpractice risk. A previous WebM&M commentary discussed patient complaints as safety …
Molina G, Berry WR, Lipsitz S, et al. Ann Surg. 2017;266:658-666.
… Annals of surgery … Ann Surg … Establishing a robust culture of safety , in which all staff feel free to … culture. This study reports on the baseline results of a program that sought to improve surgical safety at hospitals … among operating room personnel in 31 hospitals using a validated instrument. The investigators found a relatively …
Duclos A, Peix JL, Piriou V, et al. Br J Surg. 2016;103:1804-1814.
… Surg … Teamwork training programs have been implemented in a large variety of health care settings, and growing evidence suggests a positive impact. However, the effect of teamwork training … this randomized study, researchers examined whether adding a team training program to surgical safety checklist …
Tsai TC, Jha AK, Gawande AA, et al. Health Aff (Millwood). 2015;34:1304-1311.
… hospitals used more effective management practices, i.e., they consistently set quality targets and had a greater … and quality at the hospital level. One health system's approach to leadership emphasis on quality and safety is discussed in a past AHRQ WebM&M perspective . … Tsai TC, Jha AK, Gawande AA, Huckman RS, …
Gawande A. The New Yorker. May 2015
… concern . This magazine article provides insights from a surgeon about how providing unnecessary care can contribute … overdiagnosis , and overtreatment. A previous AHRQ WebM&M perspective explored overuse as a patient safety problem. … Gawande A. The New Yorker. May 2015 … A. … GawandeA. … A. …