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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 - 19 of 19 Results
Coffey M, Marino M, Lyren A, et al. JAMA Pediatr. 2022;176:924-932.
The Partnership for Patients (P4P) program launched hospital engagement networks (HEN) in 2011 to reduce hospital-acquired harms. This study reports on the outcomes of eight conditions from one HEN, Children's Hospitals' Solutions for Patient Safety (SPS). While the results do show a reduction in harms, the authors state earlier claims of improvement may have been overstated due to failure to not adjust for secular improvements. The co-director of Partnership for Patients, Dr. Paul McGann, was interviewed in 2016 for a PSNet perspective.
Winning AM, Merandi J, Rausch JR, et al. J Patient Saf. 2021;17:531-540.
Healthcare professionals involved in a medical error often experience psychological distress. This article describes the validation of a revised version of the Second Victim Experience and Support Tool (SVEST-R), which was expanded to include measures of resilience and desired forms of support.
Bartman T, Merandi J, Maa T, et al. Jt Comm J Qual Patient Saf. 2021;47:526-532.
Safety II is a proactive approach to improving patient safety by learning from what goes right in healthcare. A US children’s hospital developed three tools for frontline clinicians to recognize, mitigate, and learn from potential safety issues at the bedside.
Maa T, Scherzer DJ, Harwayne-Gidansky I, et al. J Allergy Clin Immunol Pract. 2020;8:1239-1246.e3.
This simulation study involved 28 hospitals in 6 countries to characterize medication errors involving epinephrine administration for pediatric anaphylaxis. The study found that medication administration errors were common and identified latent safety threats (including related to the use of cognitive aids) at several institutions.
Merandi J, Winning AM, Liao NN, et al. J Patient Saf Risk Manag. 2018;23:231-238.
Clinicians who experience negative emotional consequences after adverse events are considered second victims. This study evaluated health care provider satisfaction with a second victim peer support program in neonatal intensive care units. Many clinicians were unaware of the program but those who had used it expressed satisfaction. The authors conclude that specific efforts to raise awareness of and engagement with peer support for second victims is warranted.
Merandi J, Vannatta K, Davis T, et al. Pediatrics. 2018;141:e20180018.
The traditional approach to patient safety, frequently referred to as Safety-I, involved responding to adverse events and near misses after they happened. Safety-II is characterized by a more proactive approach that focuses on ensuring actions go as planned. This qualitative and exploratory study sought to understand whether Safety-II behaviors and system aspects contributed to the low adverse drug event rates observed in a single pediatric intensive care unit.
Lyren A, Brilli RJ, Zieker K, et al. Pediatrics. 2017;140.
Improving patient safety often involves multifaceted interventions intended to change complex workflows. This prospective cohort study examined whether a collaborative improvement initiative across 33 pediatric hospitals could augment patient safety. Hospitals volunteered to be part of the collaborative and paid an annual fee to participate. All but one submitted their safety data for inclusion in the study. The intervention involved identification and dissemination of evidence-based practices to reduce hospital-acquired conditions and prevent serious adverse events. Each hospital implemented these best practices locally according to their preferences. The collaborative provided virtual and in-person training for patient safety processes, such as unit-based safety rounds, root cause analysis, and inclusion of patients and families on hospital committees. Rates of hospital-acquired conditions and serious adverse events declined over time during the 3-year study. Because there were no concurrent control hospitals, it is not clear whether these improvements can be attributed to the intervention. The authors conclude that participation in a learning collaborative can enhance patient safety.
Bartman T, McClead RE. Pediatr Rev. 2016;37:407-417.
This review discusses key patient safety concepts such as systems thinking, the role of leadership in a culture of safety, use of failure analysis tools, and the value of teams in establishing efforts and behaviors that result in sustainable improvement.
Berry JC, Davis JT, Bartman T, et al. J Patient Saf. 2020;16:130-136.
A culture of safety is a fundamental component of patient safety. Several validated survey tools are available to measure hospital safety and teamwork climates, including the AHRQ Surveys on Patient Safety Culture and the Safety Attitudes Questionnaire (SAQ). Improvements in SAQ scores have been previously linked to reductions in specific safety outcomes, such as maternal and fetal adverse events in an obstetric ward. This study explored SAQ results and outcomes across all inpatient and outpatient care units in a large academic health system. Beginning in 2009, Nationwide Children's Hospital in Ohio introduced a comprehensive patient safety and high reliability program that included numerous quality improvement activities and extensive training in error prevention for each of their approximately 10,000 employees. Over the course of 4 years, SAQ scores improved while all-hospital harm, serious safety events, and severity-adjusted hospital mortality all decreased significantly. A prior WebM&M interview with J. Bryan Sexton, the primary author of the SAQ instrument, discussed the relationship between culture and safety.
Krzan KD, Merandi J, Morvay S, et al. Am J Health Syst Pharm. 2015;72:563-7.
The term "second victims" was coined to describe clinicians who commit errors, acknowledging the significant emotional impact that errors can have on the clinicians involved. A structured program to provide immediate support to clinicians affected by medical errors was well received by the pharmacy staff at a pediatric hospital.
Brady PW, Zix J, Brilli RJ, et al. BMJ Qual Saf. 2015;24:203-211.
Allowing families to activate medical emergency teams (METs) may aid in the early detection of clinical deterioration. However, physicians have expressed concerns that families do not understand when an MET is necessary and that this responsibility could present an undue stress on family members. This study reports on the experience of family-activated MET calls over a 6-year period at an academic children's hospital. There were 83 family-activated MET calls, representing less than 3% of all MET responses at this hospital. Families most frequently requested METs for concerns regarding clinical deterioration, but less than one-quarter of these calls resulted in patients being transferred to an intensive care unit, compared to 60% of clinician-activated METs. Since families called METs only between one to two times per month, the program was not felt to pose a substantial burden. The authors also point out that some family-activated METs identified other clinically relevant information that may not have otherwise been shared with the primary clinical team, as well as important communication issues that could have led to adverse events.
Brilli RJ, McClead RE, Crandall W, et al. J Pediatr. 2013;163:1638-1645.
The focus of safety programs is shifting from targeting individual types of errors to building systems to ensure safety across multiple domains. In this study from a children's hospital, implementation of a broad-based organizational safety improvement program that emphasized safety culture resulted in a sustained decrease in different types of preventable harm over a 3-year period.