Skip to main content

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.

Search All Content

Search Tips
Save
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Additional Filters
Displaying 1 - 20 of 119 Results
Temkin-Greener H, Mao Y, McGarry B, et al. J Am Med Dir Assoc. 2022;23:1997-2002.e3.
Long-term care facilities can struggle with establishing a safety culture. Researchers in this study adapted the AHRQ Surveys on Patient Safety Culture™ (SOPS®) Nursing Home Survey to assess patient safety culture in assisted living facilities. Findings show that direct care workers had significantly worse perceptions of patient safety culture (including nonpunitive responses to mistakes, management support for resident safety, and teamwork) compared to administrators. A PSNet perspective discusses how to change safety culture.
Pun BT, Jun J, Tan A, et al. Am J Crit Care. 2022;31:443-451.
Team collaboration is an essential part of ensuring patient safety in acute care settings. This survey of care team members (including nurses, physicians, pharmacists, respiratory therapists, and rehabilitation therapists) assessed teamwork and collaboration across 68 intensive care units (ICUs). Teamwork and work environment were rated favorably but care coordination and meaningful recognition were rated least favorably.
M. Violato E. Can J Respir Ther. 2022;58:137-142.
Healthcare trainees and junior clinicians are often reluctant to speak up about safety concerns. This qualitative study found that simulation training to enhance speaking up behaviors had lasting effects among advanced care paramedics and respiratory therapists as they moved from training into practice. Respondents highlighted the importance of experience for speaking up and the benefits of high-impact simulation training.
Wilson M-A, Sinno M, Hacker Teper M, et al. J Patient Saf. 2022;18:680-685.
Achieving zero preventable harm is an ongoing goal for health systems. In this study, researchers developed a five-part strategy to achieve high-reliability and eliminate preventable harm at one regional health system in Canada – (1) engage leadership, (2) develop an organization-specific patient safety framework, (3) monitor specific quality aims (e.g., high-risk, high-cost areas), (4) standardize the incident review process, including the use of root cause analysis, and (5) communicate progress to staff in real-time via electronic dashboards. One-year post-implementation, researchers observed an increase in patient safety incident reporting and improvements in safety culture, as well as decreases in adverse events such as falls, pressure injuries and healthcare-acquired infections.
Hacker CE, Debono D, Travaglia J, et al. J Health Organ Manag. 2022;36:981-986.
Disinfection and cleaning of the hospital environment can promote a reduction in healthcare-associated infections. This commentary discussed the important, yet largely invisible, role of the hospital cleaning workforce. The authors also describe additional benefits provided by cleaners, such as reducing patient isolation and alerting clinical staff to patient changes.
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).
Adapa K, Ivester T, Shea CM, et al. Jt Comm J Qual Patient Saf. 2022;48:642-652.
Tiered huddle systems (THS) include staff at all levels of the organization- frontline healthcare workers, managers, directors, and executives- and have been shown to increase adverse event reporting and improve safety culture. This US health system implemented a three-level THS in hospital and ambulatory settings to increase event reporting. Based on an interrupted time series analysis, reporting increased for total safety events, including near misses.
Hunter J, Porter M, Williams B. Australas Emerg Care. 2022;Epub Aug 29.
Situational awareness (SA) requires recognizing situations, interpreting them, and predicting how the situation may unfold in the future. Paramedics and emergency medical technicians (EMT) participated in a video simulation to assess their SA at each of the three stages. Quantitative results indicated the providers were not situationally aware during the simulation.
Schilling S, Armaou M, Morrison Z, et al. PLoS ONE. 2022;17:e0272942.
Effective teamwork is critical in acute and intensive care settings. This systematic review of reviews and thematic analysis identified four key factors that frame the evidence on interprofessional teams in acute and intensive care settings – (1) team internal procedures and dynamics, such as cohesion, organizational culture, and leadership influence; (2) communicative processes; (3) organizational and team-extrinsic influences, such as team composition, hierarchy, and interprofessional dynamics, and; (4) team outcomes, including both patient and staff outcomes.

Dzau VJ, Kirch D, Murthy V, Nasca T, eds; NAM’s Action Collaborative on Clinician Well-Being and Resilience. Washington DC: The National Academies Press; 2022. ISBN 9780309694674.

Concerted effort has been undertaken to understand the impact of clinician burnout on patient safety. This report represents the culmination of a six-year effort to design a national multidisciplinary plan to address system issues that affect the wellbeing of clinicians. The plan highlights 7 priorities to focus effort to installing and sustaining workplace environments that support clinician health such as effective use of technology, commitment to diversity and inclusion, and support of mental health. 
WebM&M Case August 31, 2022

A 71-year-old man presented to a hospital-based orthopedic surgery clinic for a follow-up evaluation of his knee and complaints of pain and swelling in his right shoulder. His shoulder joint was found to be acutely inflamed and purulent fluid was aspirated from his shoulder. The patient was sent to the Emergency Department (ED) for suspected septic arthritis.

Kosydar-Bochenek J, Krupa S, Religa D, et al. Int J Environ Res Public Health. 2022;19:9712.
A positive safety climate can improve patient safety and worker wellbeing. The Safety Attitudes Questionnaire (SAQ) was distributed to physicians, nurses, and paramedics in five European countries to assess and compare safety climate between professional roles, countries, and years of healthcare experience. All three groups showed positive attitudes towards patient safety, stress recognition, and job satisfaction; however, overall scores were low.
Thiele L, Flabouris A, Thompson C. PLoS ONE. 2022;17:e0269921.
Patient and family engagement is essential for safe healthcare. This single-site study found that while most clinicians perceived that patients and families are able to recognize clinical deterioration, clinicians expressed less favorable perceptions towards escalation processes when patients or families have concerns about clinical deterioration.
Hurley VB, Boxley C, Sloss EA, et al. J Patient Saf Risk Manag. 2022;27:181-187.
Research has shown wide variation in error reporting by profession, with nurses reporting substantially more often than physicians. This study explored not only report rates by profession, but also across departments and event types. Results indicate physicians and technicians are more likely to report errors from across departmental boundaries , while nurses and physicians report a wider variety of error types.
Walker D, Moloney C, SueSee B, et al. Prehosp Emerg Care. 2022;Epub Jun 27.
Safe medication management practices are critical to providing safe care in all healthcare settings. While there are studies reporting a variety of prehospital adverse events (e.g., respiratory and airway events, communication, etc.), there have been few studies of medication errors that occur in prehospital settings. This mixed methods systematic review of 56 studies and case reports identifies seven major themes such as organizational factors, equipment/medications, environmental factors, procedure-related factors, communication, patient-related factors, and cognitive factors as contributing to safe medication management.
Wang M, Banda B, Rodwin BA, et al. J Patient Saf. 2022;18:624-629.
Prior studies have examined students’ ability to recognize safety hazards in patient rooms using simulation; however, most of these studies focus on a single type of healthcare provider (e.g., medical or nursing students).  This study compared physicians, nurses, and other healthcare workers and found that nurses identified more hazards than other providers. All healthcare workers were challenged to identify hazards of omission and those requiring two-step thinking.
Farrell TW, Butler JM, Towsley GL, et al. Int J Environ Res Public Health. 2022;19:5975.
A robust culture of safety encourages open communication between team members. Certified nursing assistants (CNAs) and nurses in nursing homes were asked about the extent to which their input about residents was valued by the other team members. CNAs reported they felt valued by other CNAs and nurses, but less valued by physicians and pharmacists.
Hoff JJ, Zimmerman A, Tupetz A, et al. Prehosp Emerg Care. 2022;Epub May 6.
Involvement in serious adverse events can cause clinicians to feel significant and ongoing emotional trauma. Interviews with eight emergency medical service (EMS) personnel revealed self-perceived errors were more likely to result in feelings of shame, and a positive safety culture supported recovery and resilience.
Loerbroks A, Vu-Eickmann P, Dreher A, et al. Int J Environ Res Public Health. 2022;19:6690.
Work engagement may be a beneficial counterpart to burnout among health care workers. This cross-sectional study explored the association between work engagement scores with self-reported concerns about having made medical errors among medical assistants in Germany.

Farnborough, UK: Healthcare Safety Investigation Branch; June 2022.

Handoffs between prehospital emergency medical services (EMS) providers and hospital emergency departments (EDs) can be suboptimal, which increases patient harm potential. This interim 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.