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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Pilot implementation of a health equity checklist to improve the identification of equity-related adverse events.

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Patient Safety Innovation March 29, 2023

Minoritized patients continue to experience disproportionately high rates of maternal morbidity and mortality. This hospital developed a health-equity checklist to identify if bias and/or social determinants of health played a role in preventable adverse events.

Surveys on Patient Safety Culture Nursing Home Survey: 2023 User Database Report.

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Hare R, Tyler ER, Tapia A, et al. Rockville, MD: Agency for Healthcare Research and Quality; January 2023. AHRQ Publication No. 23-0018.

The AHRQ Surveys on Patient Safety Culture™(SOPS®) Nursing Home Survey assesses safety culture and resident safety in nursing homes. This report summarizes survey data from 3,224 staff working in 62 nursing homes. Respondents reported positive perceptions about both resident safety overall and feedback and communication regarding safety incidents. Areas for improvement included sufficient staffing to handle the workload and maintain resident safety.

2022 Updated Results for the AHRQ Surveys on Patient Safety Culture Workplace Safety Supplemental Item Set for Hospitals.

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Hare R, Tyler ER, Tapia A, Fan L, et al. Rockville, MD: Agency for Healthcare Research and Quality; November 2022. AHRQ Publication No. 22(23)-0008.

… No. 22(23)-0008. … Gray L, Sorra J … L … S … ND … K … T … Fan … Ji … Yount … Zebrak … Famolaro … L Fan … S Ji … ND Yount … K Zebrak … T Famolaro …

Action Planning Tool for the AHRQ Surveys on Patient Safety Culture.

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Yount N, Edelman S, Sorra J, et al. Rockville, MD: Agency for Healthcare Research and Quality; November 2022. AHRQ Publication No. 23-0011.

Improving the culture of safety within health care is an essential component of preventing or reducing errors. Designed for users of the AHRQ safety culture surveys, this updated tool will help organizations develop an action plan and proactively discuss potential barriers to safety culture improvement efforts and how to address them. The revision is structured around a 3-step process that focuses on areas to improve, initiative planning, and plan communication. The kit now includes an action plan template.

Surveys on Patient Safety Culture (SOPS) Hospital Survey 2.0: 2022 User Database Report.

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Hare R, Tapia A, Tyler ER, Fan L, et al. Rockville, MD: Agency for Healthcare Research and Quality; October 2022. AHRQ Publication No. 22(23)-0066.

Instituting a culture of safety is fundamental to ensuring patient and staff safety. The AHRQ Surveys on Patient Safety Culture™ (SOPS®) Hospital Survey is a validated survey that has been widely used to assess patient safety culture since 2004. The 2022 report includes data from 400 hospitals. The highest “percent positive” composite measure scores included both effective teamwork and supervisor, manager, or clinical leader support for suggestions for improving patient safety, and addressing patient safety concerns. Overall, when asked to rate their unit/work area on patient safety, 67 percent of respondents rated their unit/work area as “Excellent” or “Very Good.”

Nursing Home Survey on Patient Safety Culture.

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Rockville, MD: Agency for Healthcare Research and Quality; October 2020.

… using the management tool effectively. It includes a user's guide that explains how to conduct a survey on patient … 2020. … Agency for Healthcare Research and Quality; AHRQ … J … M … S … Sorra … Franklin … Streagle … J Sorra … M Franklin … S …

Development, pilot study, and psychometric analysis of the AHRQ Surveys on Patient Safety Culture (SOPS) Workplace Safety Supplemental Items for Hospitals.

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Zebrak K, Yount N, Sorra J, et al. Int J Environ Res Public Health. 2022;19:6815.

… Int J Environ Res Public Health … AHRQ’s Hospital Survey on Patient Safety (SOPS) is used by … safety; and workplace safety reporting. … Zebrak K, Yount N, Sorra J, et al. Development, pilot study, and …

2022 Updated Results for the AHRQ Surveys on Patient Safety Culture (SOPS) Diagnostic Safety Supplemental Items.

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Famolaro T, Hare R, Tapia A, et al. Rockville, MD: Agency for Healthcare Research and Quality; April 2022. AHRQ Publication No. 22-0027.

… of discussions about misdiagnoses when they occurred. … Famolaro T, Hare R, Tapia A, et al. Rockville, MD: Agency for … April 2022. AHRQ Publication No. 22-0027. … Fan L, Ji S, Yount ND, Gray L, Zebrak K, Sorra J …

Surveys on Patient Safety Culture (SOPS) Medical Office Survey: 2022 User Database Report.

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Famolaro T, Hare R, Tapia A, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2022. AHRQ Publication No. 22-0017.

… , the lowest-scoring measure was work pressure and pace. … Famolaro T, Hare R, Tapia A, et al. Rockville, MD: Agency for … Publication No. 22-0017. … Taie-Tehrani S, Fan L, Liu H, Yount ND, Sorra J …

Organizational safety climate and job enjoyment in hospital surgical teams with and without crew resource management training,

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Bacon CT, McCoy TP, Henshaw DS, et al. J Nurs Adm. 2021;51:e20-e26.

… J Nurs Adm … Organizational safety climate (OSC) has been … teams with and without crew resource management training. J Nurs Adm. 2021;51(11):e20-e26. …

Surveys on Patient Safety Culture™ (SOPS®) Ambulatory Surgery Center Survey: 2021 User Database Report.

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Famolaro T, Hare R, Tapia A, Yount et al. Rockville, MD: Agency for Healthcare Research and Quality; December 2021. AHRQ Publication No. 22-0004.

… as committed to learning and continuous improvement. … Famolaro T, Hare R, Tapia A, Yount et al. Rockville, MD: Agency for Healthcare Research …

Malpractice cases in breast surgery: an assessment of litigation involving surgeons.

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Fan B, Pardo J, Yu-Moe CW, et al. Ann Surg Oncol. 2021;28:8109-8115.

… nosocomial infection were the top 5 injury descriptions. … Fan B, Pardo J, Yu-Moe CW, et al. Malpractice cases in breast surgery: an …

Trauma Resuscitation Using in situ Simulation Team Training (TRUST) study: latent safety threat evaluation using framework analysis and video review.

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Petrosoniak A, Fan M, Hicks CM, et al. BMJ Qual Saf. 2021;30:739-746.

… capacity, and task-specific issues. … Petrosoniak A, Fan M, Hicks CM, et al. Trauma Resuscitation Using in situ …

Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions.

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Morris AH, Stagg B, Lanspa M, et al. J Am Med Inform Assoc. 2021;28:1330-1344.

… J Am Med Inform Assoc … Clinical decision support systems are … produce replicable and personalized clinician actions. J Am Med Inform Assoc. 2021;28(6):1330-1344. …

Medical Office Survey: 2020 User Database Report.

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Famolaro T, Hare R, Thornton S, et al. Surveys on Patient Safety CultureTM (SOPSTM). Rockville, MD: Agency for Healthcare Research and Quality; March 2020. AHRQ Publication No. 20-0034.

… associated with productivity pressures in health care. … Famolaro T, Hare R, Thornton S, et al. Surveys on Patient Safety CultureTM …

Surveys on Patient Safety Culture(TM) (SOPS®) Hospital Survey 2021 User Database Reports.

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Famolaro T, Hare R, Yount ND, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2021. AHRQ Publications Nos. 21-0016(1.0) and 21-0017(2.0).

… Report noted concerns about staffing and work pace. … Famolaro T, Hare R, Yount ND, et al. Rockville, MD: Agency for Healthcare …

Exploring the association between organizational safety climate, failure to rescue, and mortality in inpatient surgical units.

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Bacon CT, McCoy TP, Henshaw DS. J Nurs Adm. 2021;51(1) :12-18.

… J Nurs Adm … Lack of communication and interpersonal dynamics … to rescue, and mortality in inpatient surgical units. J Nurs Adm. 2021;51(1):12-18. Epub 2020/12/06. …

Linking patient safety culture to quality ratings in the nursing home setting.

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Yount N, Zebrak KA, Famolaro T, et al. J Appl Gerontol. 2021;41:73-81.

… which is consistent with other earlier findings. … Yount N, Zebrak KA, Famolaro T, et al. Linking patient safety culture to quality ratings …

Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical centers, April-June 2020.

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Self WH, Tenforde MW, Stubblefield WB, et al. MMWR Morb Mortal Wkly Rep. 2020;69:1221-1226.

This study examined the prevalence and risk factors for COVID-19 infection among frontline healthcare personnel who work with COVID-19 patients. Serum specimens were collected from a convenience sample of 3,248 frontline personnel between April 3 and June 19, 2020. Six percent (6%) tested positive for SARS-CoV-2 antibodies; a high proportion of these individuals did not suspect that they had been previously infected. This study highlights the role that asymptomatic COVID-19 infections play and authors suggest that enhanced screening and universal use of face coverings in hospitals are two strategies to reduce COVID-19 transmissions in healthcare settings.

Surveys on Patient Safety Culture (SOPS) Ambulatory Surgery Center Survey: 2020 User Database Report.

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Famolaro T, Hare R, Thornton S, et al. Rockville, MD: Agency for Healthcare Research and Quality; January 2020. AHRQ Publication No. 20-0016.

The latest publication from the Agency for Healthcare Research and Quality (AHRQ) reports results of 282 ambulatory surgery centers (ASC) participating in the Surveys on Patient Safety Culture (SOPS) Ambulatory Surgery Center Survey. The majority of respondents (86%) rated their organization’s overall safety rating as excellent or very good.

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