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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 63 Results
Gupta AB, Greene MT, Fowler KE, et al. J Patient Saf. 2023;19:447-452.
As high workload and interruptions are known contributors to diagnostic errors, significant research has been conducted to understand and ameliorate the impact of these factors. This study examined the association between hospitalist busyness (i.e., number of admissions and pages), resource utilization, number of differential diagnoses, and the hospitalist's diagnostic confidence and subjective awareness. Increasing levels of busyness were associated with hospitalists reporting it was "difficult to focus on what is happening in the present" but had no effect on diagnostic confidence.
Gilmartin HM, Saint S, Ratz D, et al. Infect Control Hosp Epidemiol. 2023;Epub Sep 13.
Burnout has been reported across numerous healthcare settings and disciplines during the COVID-19 pandemic. Among US hospital infection preventionists surveyed in this study, nearly half reported feeling burnt out, but strong leadership support was associated with lower rates of burnout. Leadership support was also associated with psychological safety and a stronger safety climate.
Levy KL, Grzyb K, Heidemann LA, et al. J Grad Med Educ. 2023;15:348-355.
The quality improvement and patient safety (QIPS) curriculum is increasingly being added to resident education, but implementation and quality of these programs varies. In this study, continuous improvement specialists (CIS) were embedded in resident teams to create an A3, a quality improvement tool. A key component to the QIPS curriculum was aligning resident projects with quality improvement efforts already underway in the department.
Saint S, Greene MT, Krein SL, et al. Infect Control Hosp Epidemiol. 2023;Epub Jun 1.
The COVID-19 pandemic challenged infection prevention and control practices. Findings from this survey of infection prevention professionals from acute care hospitals in the United States found that while CLABSI and VAE preventive practices either increased or remained consistent, use of CAUTI preventive practices decreased during the pandemic.
Lafferty M, Harrod M, Krein SL, et al. J Am Med Inform Assoc. 2021;28:28(12).
Use of one-way communication technologies, such as pagers, in hospitals have led to workarounds to improve communication. Through observation, shadowing, interviews, and focus groups with nurses and physicians, this study describes antecedents, types, and effects of workarounds and their potential impact on patient safety.
Chopra V, O'Malley M, Horowitz J, et al. BMJ Qual Saf. 2022;31:23-30.
Peripherally inserted central catheters (PICC) represent a key source of preventable harm. Using the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC), the authors sought to determine if the appropriateness of PICC use decreased related medical complications including catheter occlusion, venous thromboembolism, and central line-associated bloodstream infections. Use of MAGIC in 52 Michigan hospitals increased appropriate use of PICC lines and decreased medical complications. In a 2019 PSNet Perspective, Dr. Vineet Chopra described the development and implementation of MAGIC in Michigan hospitals.  
Manojlovich M, Harrod M, Hofer TP, et al. BMJ Qual Saf. 2021;30:747-754.
Communication failures can lead to patient harm. Based on observations, interviews, and focus groups with nurses and physicians, the authors found that physician responsiveness to communications from bedside nurses depends on a combination of factors including the clarity of the message, physician preference for one communication via text, page, phone call, and other factors, such as trust, interpersonal relationships, and different clinical perspectives.
Greene MT, Gilmartin HM, Saint S. Am J Infect Control. 2020;48:2-6.
This cross-sectional study reports the results of an ongoing national survey of infection preventionists to assess hospital infection control program characteristics and organizational practices to prevent common healthcare-associated infections. One-third of responding hospitals reported characteristics of organizational safety culture (e.g. employee perceptions of feeling safe to speak up, ask for help, or provide feedback), which was associated with increased odds of using some recommended practices for preventing catheter-associated urinary tract infections and ventilator-associated pneumonia.
Quinn M, Forman J, Harrod M, et al. Diagnosis (Berl). 2019;6:241-248.
Prior research has found that diagnostic errors comprise approximately one-fifth of preventable errors among hospitalized patients. Academic clinical care poses unique risks for diagnostic error because the frontline providers are residents and medical students. Thus, accurate diagnosis relies on robust communication between learners and their supervisors. A team of social scientists and clinicians conducted an ethnographic study of physicians on academic inpatient rounds to identify barriers to timely and correct diagnoses. They found that reliance on one-way communication methods and insufficient face-to-face interactions with patients and consultants hindered effective diagnostic decision-making. Additionally, the electronic health record led to data overload and data fragmentation. The authors offer concrete suggestions for more clinician- and patient-centered technical tools. A WebM&M commentary discussed a diagnostic error involving learners in psychiatry.
Saint S, Greene MT, Fowler KE, et al. BMJ Qual Saf. 2019;28:741-749.
This study focused on three types of device-associated infections: catheter-associated urinary tract infection (CAUTI), central line–associated bloodstream infection (CLABSI), and ventilator-associated pneumonia (VAP). Investigators surveyed hospital infection control leaders at 528 hospitals about prevention practices for each of these infections. More than 90% of respondents had established surveillance for CAUTI rates throughout their facilities, nearly 100% used two key CLABSI prevention techniques as part of their insertion protocol, and 98% used semirecumbent positioning to prevent VAP. Gaps remain in use of antimicrobial devices across all three of these infection types. The authors conclude that, although implementation of evidence-based infection practices are improving over time, some gaps in device-associated infection prevention persist. A past PSNet perspective discussed the history around efforts to address preventable hospital-acquired infections.
Umberfield E, Ghaferi AA, Krein SL, et al. Jt Comm J Qual Patient Saf. 2019;45:406-413.
Communication failures are a common underlying factor in adverse events. Although the relationship between communication failures and safety has been best studied in the operating room, this issue likely contributes to safety problems in all settings of care. Investigators examined incident reports at an academic medical center to characterize how communication problems contribute to adverse events. Errors of purpose—a type of error in which the goals of the communication event remain unresolved, implying that situational awareness was not achieved—were among the most common types of communication problems identified. The authors point out that while structured communication tools (such as the I-PASS handoff tool) can improve the accuracy and completeness of information transfer, they are not well suited to improving communication in clinically ambiguous situations. Communication problems most often led to delays in care without physical harm, highlighting the difficulty of measuring communication issues compared to other types of safety events. A WebM&M commentary discussed a series of communication errors that led to a child's death.
Manojlovich M, Frankel RM, Harrod M, et al. BMJ Qual Saf. 2019;28:160-166.
Researchers describe the use of video reflexive ethnography to improve communication between physicians and nurses during rounds at a single academic medical center. They conclude that video reflexive ethnography is feasible and may have the potential to improve communication between physicians and nurses.
WebM&M Case February 1, 2019
A woman was admitted to a hospital's telemetry floor for management of uncontrolled hypertension and palpitations. On the first hospital day, she complained of right arm numbness and weakness and had new difficulty answering questions. The nurse called the hospitalist and relayed the arm symptoms, but not the word-finding difficulty. The hospitalist asked the nurse to call for a neurology consultation. Four hours later, the patient's weakness had progressed; she was now completely unable to move her right arm.
Manojlovich M, Hofer TP, Krein SL. J Patient Saf. 2021;17:e732-e737.
Communication problems persistently contribute to medical error. This review focuses on the exchange of information between care team members. The authors describe an eight-element framework that targets trust, hierarchy, and technology as an approach to communication improvement that embraces the interpersonal nature of safe health care delivery.
Smith ME, Wells EE, Friese CR, et al. Health Aff (Millwood). 2018;37:1870-1876.
When a patient experiences a major surgical complication, a health care team's inability to prevent subsequent postoperative death is known as failure to rescue. Stakeholders at five Michigan hospitals identified two changeable causes of failure to rescue: delayed recognition of evolving complications and communication deficiencies. A WebM&M commentary discussed a failure to rescue and system-level means to address the adverse outcome.
Gupta A, Harrod M, Quinn M, et al. Diagnosis (Berl). 2018;5:151-156.
This direct observation study of hospitalist teams on rounds and conducting follow-up work examined the interaction between systems problems and cognitive errors in diagnosis. Researchers found that information gaps related to electronic health records, challenges with handoffs, and time constraints all contributed to difficulties in diagnostic cognition. The authors suggest considering both systems and cognitive challenges to diagnosis in order to promote safety.
Vaughn VM, Saint S, Krein SL, et al. BMJ Qual Saf. 2019;28:74-84.
The literature on effective approaches to improving quality and safety generally focuses on high reliability organizations and positive deviants—organizations or units that have achieved notable successes. This systematic review sought to characterize organizations that struggle to improve quality. The authors identified five domains that exemplify struggling organizations, including lack of a clear mission and organizational structure for improving quality and inadequate infrastructure.
Krein SL, Mayer J, Harrod M, et al. JAMA Intern Med. 2018;178:1016-1057.
Infection control precautions including use of personal protective equipment (PPE) are critical for preventing transmission of infections within health care settings. This direct observation study observed frequent failures in use of PPE, including entering rooms without using PPE at all, PPE process mistakes, and slips in properly executing PPE use. The authors suggest that given the wide range of failures, a variety of strategies are needed to improve use of PPE.