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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 152 Results
Barlow M, Watson B, Morse K, et al. J Health Organ Manag. 2023;Epub Sep 26.
Hierarchy and expected response may inhibit someone from speaking up about a safety concern. This study used two vignettes of a speaking up situation with randomization on speaker seniority, discipline (i.e., allied staff, nurse, physician), tone (i.e., accommodating or non-accommodating), and the presence of other people in the room. All participants were more likely to respond positively to the accommodating tone, but the impact of seniority varied by receiver's discipline.
Bagot KL, McInnes E, Mannion R, et al. BMC Health Serv Res. 2023;23:1012.
Unprofessional behavior can have a detrimental effect on coworkers, culture, and patient safety. This qualitative study presents perspectives of middle managers in hospitals that implemented a program allowing and encouraging workers to report unprofessional, as well as positive, behavior. Themes included staying silent but active (e.g., avoiding the unprofessional colleague), history and hierarchy, and double-edged swords (e.g., pros and cons of anonymous reporting).
Cicero MX, Baird J, Brown L, et al. Prehosp Emerg Care. 2023;Epub Sep 12.
The pediatric population faces unique challenges in the prehospital setting. This prospective chart review study classified adverse safety events (ASE) of pediatric patients at 15 emergency medical services (EMS) agencies. More than 20% of encounters contained at least one ASE, although most were unlikely to cause harm (e.g., missed documentation).
Cullati S, Semmer NK, Tschan F, et al. Int J Public Health. 2023;68:1606078.
Illegitimate tasks are those that workers think they should not have to perform, either because they are unnecessary or not part of their specific role. In this study with hospital nurses, physicians, and other direct and indirect healthcare staff, 20% reported illegitimate tasks occurred frequently in their setting. Although respondents were not asked to specify illegitimate tasks, the authors hypothesize that physicians, who reported the highest prevalence of frequency of illegitimate tasks, may perceive "administrative" tasks as illegitimate.
Harrison J. Br Paramed J. 2023;8:18-28.
Patients with dark skin tones are not well represented in health education, particularly dermatology, which can result in delayed diagnosis. In this scoping review, thirteen articles were identified assessing the confidence of students and healthcare providers in assessing patients with dark skin tones.  Overall, confidence was low but tailored training somewhat improved confidence. The author asserts more research and education is needed outside dermatology, for example, when assessments use terms such as pale, redness, or blue.
Gillette C, Perry CJ, Ferreri SP, et al. J Physician Assist Educ. 2023;34:231-234.
A study conducted in 2011 concluded that pharmacy students identified more prescribing errors than their medical or nursing counterparts. This study replicates the 2011 study with first- and second-year physician assistant (PA) students. The results suggest PA students, regardless of year, identified prescribing errors at similar rates to medical and nursing students, although identification rates were low for all three student groups.
Wells M, Henry B, Goldstein L. Prehosp Disaster Med. 2023;38:471-484.
Inaccurate estimations of patient weight can lead to medication errors in the prehospital period. This systematic review of 9 studies concluded that there is insufficient evidence to assess the accuracy of weight estimation approaches used in the EMS setting or by paramedics, underscoring the need for additional, robust research in this area.

Farnborough, UK: Healthcare Safety Investigation Branch; August 2023.

Handoffs between prehospital emergency medical services (EMS) providers and hospital emergency departments (EDs) can be suboptimal, which increases patient harm potential. This report examines National Health Service discharge delays. It suggests a systemic approach is needed to address flow and capacity factors that contribute to ineffective and unsafe interfacility discharge and transfer.
Tariq MB, Ali I, Salazar‐Marioni S, et al. J Am Heart Assoc. 2023;12:e029830.
Delayed diagnosis and treatment of stroke leads to adverse patient outcomes. This cross-sectional study identified gender disparities in the treatment of patients with large vessel occlusion (LVO) acute ischemic stroke (AIS), with women being less likely to be routed directly to comprehensive stroke centers compared with men, despite having more significant stroke syndromes.

Rosen M, Dy SM, Stewart CM, et al. Making Healthcare Safer IV Series.  Rockville, MD: Agency for Healthcare Research and Quality; July 2023. AHRQ Publication no. 23-EHC019-1.

Reducing preventable harm in healthcare settings remains a national priority. This report summarizes the results of the prioritization process used to identify patient safety practices meriting inclusion in the fourth installment of the Making Healthcare Safer (MHS) series (previous installments were published in 2001, 2013, and 2020). The fifteen-member Technical Expert Panel identified 27 priority patient safety practices for examination in the forthcoming report, including several practices that have not been covered in previous MHS reports (e.g., family/caregiver engagement, preventing non-ventilator associated pneumonia, supply chain disruption, high reliability, post-event communication programs).
Péculo‐Carrasco J‐A, Luque‐Hernández MJ, Rodríguez‐Ruiz H‐J, et al. J Clin Nurs. 2023;32:4473-4491.
Emergency medical services (EMS) and pre-hospital care present unique challenges to ensure the delivery of safe care. This systematic review, including both qualitative and quantitative studies, identified four dimensions influencing patient perceptions of safety in pre-hospital care – satisfactory response from the emergency medical system, competence of EMS personnel, the setting of care/environmental factors, and patients’ personal characteristics.
Kamta J, Fregoso B, Lee A, et al. Prehosp Emerg Care. 2023;Epub Jul 28.
Handoffs from emergency medical services (EMS) to the emergency department (ED) are vulnerable to communication errors due to the time-pressured environment. This study reports on the implementation of an electronic health record (EHR) tool that added pre-hospital medication administration to the ED triage note to reduce medication administration errors (MAE). Although most ED providers reported they "always" review the triage note, MAE rates did not improve following implementation.

Renault M. Stat. July 7, 2023.

Emergency vehicle transport can be dangerous for the patient, the clinician team, and the community. This article discusses the effect of ambulance use of alarm sirens on the safety of the service. Impacts such as psychological health of the patient and access to care units, should a crash occur, are discussed.
Wilson C, Janes G, Lawton R, et al. BMJ Qual Saf. 2023;32:573-588.
Feedback interventions (e.g., debriefing, peer-to-peer, audit, and feedback) can encourage learning from safety events and improve quality of care. This systematic review of 48 studies found that providing feedback to emergency medical services (EMS) personnel can improve documentation and adherence to protocols, with some studies also documenting improvements in clinical decision-making and cardiac arrest performance.
Venesoja A, Tella S, Castrén M, et al. BMJ Open. 2023;13:e067754.
Emergency medical services (EMS) personnel encounter unique safety challenges when delivering patient care. Using focus groups and individual interviews with EMS medical directors and managers in Finland, this qualitative study explored perceptions around patient collaboration to improve safety in EMS. Participants agreed that patient safety is an organizational responsibility and management should provide EMS patients with opportunities to speak up as well as address barriers to voicing concerns.
Ališić E, Krupić M, Alić J, et al. Cureus. 2023;15:e38854.
The World Health Organization's (WHO) Surgical Safety Checklist (SSC) has resulted in improved surgical outcomes; however, use of the checklist varies. In this study, surgical personnel (surgeons, anesthesiologists, nurse anesthetists, surgical nurses, and assistant nurses) were surveyed about use of the SCC in their hospital, including who was responsible for ensuring its use. Although most groups reported it was not clear who was responsible for implementing the SSC prior to surgery, they believed it was the assistant nurse.
WebM&M Case June 28, 2023

A 56-year-old man was admitted to the hospital and required mechanical ventilation due to COVID-19-related pneumonia and acute respiratory failure. The care team performed a tracheostomy percutaneously at the bedside with some difficulty. The tracheostomy tube was secured, inspected via bronchoscopy, and properly sutured. During the next few days, the respiratory therapist noticed a leak that required additional inflation of the cuff to maintain an adequate seal.

D’Angelo A-LD, Kapur N, Kelley SR, et al. Surgery. 2023;174:222-228.
Prior research has asked surgeons how they cope with intraoperative errors, but this study asks operating room personnel how they perceive surgeons' coping strategies. Positive response strategies included announcing that an error has occurred and the plan for managing it. Negative responses include the surgeon becoming visibly upset, raising their voice, and blaming others. The authors suggest additional education on positive strategies to cope with errors during medical education and residency.
Hyvämäki P, Sneck S, Meriläinen M, et al. Int J Med Inform. 2023;174:105045.
Insufficient or incorrect transfer of patient information, whether caused by human or organizational factors, can result in adverse events during transitions of care. This study used four years of incident reports to identify the types, causes, and consequences of health information exchange- (HIE) related patient safety incidents in emergency care, (ED) emergency medical services (EMS), or home care. The two main kinds of HIE-related incidents were (1) inadequate documentation and inadequate use of information (e.g., deficiencies in content), and (2) causes related to the health professional or organization; consequences were adverse events or additional actions to prevent, avoid, and correct adverse events.