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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 89 Results
Wu G, Podlinski L, Wang C, et al. Jt Comm J Qual Patient Saf. 2022;48:665-673.
Simulation training is used to improve technical and nontechnical skills among healthcare teams. This study evaluated the impact of a one-hour interdisciplinary in situ simulation training on code response, teamwork, communication and comfort during intraoperative resuscitations. After simulation training, researchers noted improvements in technical skills of individuals and teams (e.g., CPR-related technical skills).
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.
Fraczkowski D, Matson J, Lopez KD. J Am Med Inform Assoc. 2020;27:1149-1165.
The authors reviewed studies using qualitative and quantitative methods to describe nursing workarounds related to the electronic health record (EHR) in direct care activities. Workarounds generally fit into three categories – omission of process steps, steps performed out of sequence, and unauthorized process steps. Probable causes for workarounds were identified, including organizational- (e.g., knowledge deficits, non-formulary orders), environmental-, patient- (e.g., barcode/ID not accessible), task- (e.g., insufficient time), and usability-related factors (e.g., multiple screens to complete an action). Despite nurses being the largest workforce using EHRs, there is limited research focused on the needs of nurses in EHR design.
Bloom JP, Moonsamy P, Gartland RM, et al. J Thorac Cardiovasc Surg. 2019.
… with increased team turnover and on weekends. A prior Web M&M commentary discusses adverse outcomes arising due a … object during cardiac surgery. … Bloom JP, Moonsamy P, Gartland RM, et al. Impact of staff turnover during …
Botros S, Dunn J. BMJ Open Qual. 2019;8:e000363.
A quality improvement program that used a paper-based reminder to encourage physicians to complete medication reconciliation and communicate medication changes to outpatient physicians effectively improved the accuracy of medication reconciliation at discharge in a Scottish teaching hospital's surgical ward. The intervention was successfully disseminated to other wards within the hospital.
Kaur AP, Levinson AT, Monteiro JFG, et al. J Crit Care. 2019;52:16-21.
The second victim effect has been used to describe the emotional impact that providers may experience when involved in a medical error, adverse event, or unanticipated patient outcome. In this survey study, researchers found that members of a critical care society frequently admitted to experiencing negative emotions such as blame and guilt when responding to questions involving scenarios of different types of errors. Nearly 70% of respondents suggested that team debriefings and talking with colleagues could help mitigate the second victim effect.
Badgery-Parker T, Pearson S-A, Dunn S, et al. JAMA Intern Med. 2019;179:499-505.
Overuse of unnecessary tests and procedures contributes to patient harm. In this cohort study, researchers found that patients who developed a hospital-acquired condition after undergoing a procedure that most likely should not have been performed had longer lengths of stay than patients who did not develop a hospital-acquired condition.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; November 2018. Report No. OEI-06-14-00530.
… address long-term care facilities. A past WebM&M commentary discussed safety and quality of long-term care. … Levinson DR. Washington, DC: US Department of Health and … Services; Office of the Inspector General; OIG … DR … Levinson … DR Levinson
Lee SE, Vincent C, Dahinten S, et al. J Nurs Scholarsh. 2018;50:432-440.
This secondary analysis combined survey data from individual nurses with hospital safety culture data and found that both individual characteristics such as education level and hospital characteristics such as safety culture were associated with risks of medication administration errors and falls. The authors conclude that improving safety culture should be a high priority.
McCleery A, Devenny K, Ogilby C, et al. J Healthc Risk Manag. 2019;38:11-18.
Human factors and patient safety contexts are important to consider when investigating root causes of medical care failure. This commentary describes a framework that applies elements of system safety, teamwork, and organizational culture to medicolegal data analysis. The approach enhanced identification of process weakness to inform safety improvement work. An Annual Perspective discussed the need to revisit processes for root cause analysis.
Taylor-Phillips S, Jenkinson D, Stinton C, et al. Radiology. 2018;287:749-757.
This retrospective analysis of more than 800,000 mammograms examined the effect of a second review of images. With a second reader, fewer women had to return for more imaging and more cancers were detected, suggesting that double reading may enhance the diagnostic performance of mammography.
Lee SE, Scott LD, Dahinten S, et al. West J Nurs Res. 2019;41:279-304.
This literature review found that the relationship between safety culture and patient safety outcomes is inconsistent across studies. Researchers recommend use of a theoretical framework and validated safety culture instruments to shed light on the correlation between safety culture and patient harm.

Benzon HT, Anderson TA, eds. Anesth Analg. 2017;125(5):1427-1778.

… … Brown RE Jr; Du Vivier D … A. … HA … TA … H. … B. … M. … DE … A. … M. … HT … PA … DJ … MA … CD … JE … BK … AL … … … E. … DJ … NB … SM … LR … K. … MA … S. … CL … CR … EY … P. … E. … JP … RD … JC … EM … SA … RJ … GA … D. … MS … C. … … … Cohen … Leighton … Crock … Stone … Wick … Wu … Grant … Dunn … Durieux … Nemergut … Naik … A. Zhu … HA Benzon … TA …
Dunn W, Dong Y, Zendejas B, et al. Am J Med Sci. 2017;353:158-165.
Simulation has been adopted as a valuable teaching tool in health care. This commentary reviews mastery learning theory at the individual and system levels and suggests that it can be enhanced with simulation to engineer effective processes at the organizational level.
Levinson W, Yeung J, Ginsburg S. JAMA. 2016;316:764-5.
Disclosing medical errors to patients is essential for maintaining a therapeutic relationship and preventing further harm. This commentary describes a case in which a physician inadvertently used nonsterile instruments to perform procedures on two patients and presents options for what the physician might do next. Recommended best practices for error disclosure include being honest about what happened, explicitly stating that an error occurred, and explaining to the patient any relevant specific information that might be helpful in terms of necessary follow-up. The authors suggest that all errors be formally reviewed to prevent future harm and that health care systems should create an environment that facilitates error reporting.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; July 2016. Report No. OEI-06-14-00110.
The Office of the Inspector General (OIG) has issued a series of reports analyzing the incidence and preventability of adverse events among Medicare beneficiaries receiving care in acute care hospitals and skilled nursing facilities. This report used similar methodology based on trigger tools to determine adverse event incidence among patients in rehabilitation hospitals—post-acute care facilities that provide intensive rehabilitation to patients recovering from hospitalization for an acute illness or injury. The study found that 29% of patients experienced an adverse event during their stay, a proportion nearly identical to rates at acute care hospitals and skilled nursing facilities. Nearly half of the events were considered preventable, with the most common types of events including pressure ulcers, delirium, and medication errors. Nearly one-fourth of patients who had an adverse event required transfer to an acute care hospital for diagnosis or management, leading to a large increase in costs of care. Based on these data, the OIG has recommended that the Agency for Healthcare Research and Quality and Centers for Medicare and Medicaid Services disseminate information about patient harms in the rehabilitation setting and work to improve safety at rehabilitation hospitals. A previous WebM&M commentary discussed an adverse event at a rehabilitation facility.
Staiger TO, Mills LM, Wong BM, et al. Am J Med. 2016;129:540-6.
A survey of academic medicine departments sought to identify quality improvement and patient safety activities in written promotion criteria. Investigators suggest language to use in promotion criteria that acknowledges quality and safety activities as core to clinical excellence, includes quality and safety as areas of scholarship, and delineates how the impact of these activities should be evaluated. The authors recommend that academic medical centers adopt such criteria across more institutions.
Taylor-Phillips S, Wallis MG, Jenkinson D, et al. JAMA. 2016;315:1956-65.
Interpretation of mammograms is a repetitive task, and a vigilance decrement—decreased attention after many repetitions of the same task—could impair diagnostic accuracy. However, this large randomized trial found no evidence for vigilance decrement. Investigators also determined that radiologists were equally accurate at identifying abnormalities regardless of the order in which they reviewed the studies.
Coleman DL, Wardrop RM, Levinson WS, et al. Acad Med. 2017;92:52-57.
Patient safety is recognized as a critical component of medical education. This commentary spotlights the need for faculty development in patient safety and quality improvement. The authors outline roles for individuals, appointments and promotions committees, and organizations to address this challenge.