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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 791 Results
Canadian Institute for Health Information, Health Excellence Canada.
Reducing preventable harm associated with health care is a worldwide goal. This Canadian initiative developed a measure to track unintended harm in acute care hospitals, a toolkit to accompany reduction efforts, and reports that assess the results of improvement efforts and provide data analysis.
Healthcare Excellence Canada.
This site provides promotional materials and registration information for an awareness campaign on patient safety that takes place in the autumn. The annual observance will take place October 23-27, 2023.
Khan WU, Seto E. J Med Internet Res. 2023;25:e43386.
Artificial intelligence (AI) and machine learning (ML) are emerging as tools to improve patient care, but they are not without risks. This article proposes use of a safety checklist to determine readiness to launch AI technologies, prompting users to consider physical and mental health and economic and social risks and benefits.
Zavalkoff S, O’Donnell S, Lalani J, et al. Can J Anaesth. 2023;70:886-892.
Lack of timely identification and referral of potential organ donors and poor communication can lead to missed opportunities for life-saving organ transplants. This analysis of data from Canadian organ donation organizations estimates that there were 354 potentially missed transplants between 2016 and 2018.
Pozzobon LD, Lam J, Chimonides E, et al. Healthc Manage Forum. 2023;36:241-245.
High-reliability organizations are able to achieve safety despite organizational changes or other hazardous conditions. This article describes the implementation of a new electronic health record (EHR) system at one academic health system in Canada and provides examples of how high-reliability principles informed activities to prevent patient harm during this organizational change.
Redstone CS, Zadeh M, Wilson M-A, et al. J Patient Saf. 2023;19:173-179.
Previous research has found that central line-associated blood stream infections (CLABSIs) increased during the COVID-19 pandemic. This article describes the development, implementation, and evaluation of a quality improvement initiative (QI) at one community health system in Canada to reduce CLABSIs between July 2019 and May 2022. The QI initiative included changes in six areas – organizational oversight and accountability, education and training, standardized central line processes, optimized central line equipment, improving data and reporting, and fostering a culture of safety. Over the study period, CLABSIs were reduced by 51% and the use of both central line insertion checklists and central line capped lumens increased.
Jeffs L, Bruno F, Zeng RL, et al. Jt Comm J Qual Patient Saf. 2023;49:255-264.
Implementation science is the practice of applying research to healthcare policies and practices. This study explores the role of implementation science in the success of quality improvement projects. Inclusion of expert implementation specialists and coaches were identified as best practices for successful quality improvement and patient safety projects. COVID-19 presented challenges for some facilities, however, including halting previously successful projects.
Liang MQ, Thibault M, Jouvet P, et al. BMJ Health Care Inform. 2023;30(1):e100622.
Computerized provider order entry (CPOE) systems are widely used and can help prevent medication administration errors. This mixed-methods study examined the impact of CPOE on medication safety in the pediatric department at one Canadian hospital. Researchers found that most errors occurred during the medication administration step rather than the prescribing step. The researchers also observed a non-statistically significant decrease in medication errors overall, which was primarily attributed to significant improvements in errors during order acknowledgement, transmission, and transcription.
Ledlie S, Gomes T, Dolovich L, et al. Explor Res Clin Soc Pharm. 2023;9:100218.
Mandatory error reporting systems can help identify types, causes, and solutions to medication-related errors. More than 30,000 medication-related incidents were reported by community pharmacists to the Assurance and Improvement in Medication (AIMS) Program in Canada. Event type, severity, medication class, and method of detection are described. Only 60% of pharmacies submitted at least one report, indicating compliance with and participation in the AIMS Program remains low.
Curated Libraries
March 8, 2023
Value as an element of patient safety is emerging as an approach to prioritize and evaluate improvement actions. This library highlights resources that explore the business case for cost effective, efficient and impactful efforts to reduce medical errors.

Derfel A. Montreal Gazette. February 24- March 1, 2023

Emergency room failures are often rooted in system weaknesses. This series examines six patient deaths associated with emergency care that, while concerns were raised by nursing staff, have not been explored to initiate improvements at the facility. Factors contributing to the deaths discussed include nurse shortages, inconsistent oversight, and poor training.
Ducey A, Donoso C, Ross S, et al. Sociol Health Illn. 2023;45:346-365.
Research has identified variations in treatment that are unlikely to be related to patient characteristics, such as region. In this study, surgeons describe their preferences for and experiences with a device which caused widespread harm to women and was ultimately recalled by several patient safety agencies: transvaginal mesh for the treatment of pelvic floor devices in women. Even when surgeons arrived at the same decision (to perform surgery or not), wide variations were observed during the decision-making process.
Borycki EM, Kushniruk AW. Healthc Manage Forum. 2023;51:212-221.
Health technology has improved many aspects of care, but can also introduce new safety concerns that require active monitoring and improvement. This commentary describes how learning health systems can improve the safety of new technologies, such as hiring health informaticists and collaborations with health authorities and vendors.

Healthcare Excellence Canada. 2020-2023.

This bi-monthly webinar series focuses on a variety of topics that support patient safety and quality improvement.
Aubin DL, Soprovich A, Diaz Carvallo F, et al. BMJ Open Qual. 2022;11:e002004.
Healthcare workers (HCW) and patients can experience negative psychological impacts following medical error; the negative impact can be compounded when workers and patients are prevented from processing the error. This study explored interactions between patients/families and HCWs following a medical error, highlighting barriers to communication, as well as the need for training and peer support for HCWs. Importantly, HCW and patients/families expressed feeling empathy towards the other and stressed that open communication can lead to healing for some.
Skead C, Thompson LH, Kuk H, et al. Crit Care Res Pract. 2022;2022:4815734.
After-hours and weekend admissions to the hospital and intensive care units (ICU) have been linked to poor outcomes. This retrospective analysis compared outcomes among adult patients with daytime versus nighttime ICU admissions at one large Canadian medical center in between 2011 and 2015. Researchers found that overall mortality, but not ICU mortality, was higher among daytime admissions.
Klasen JM, Teunissen PW, Driessen E, et al. Med Educ. 2023;57:430-439.
Learning to recover after a medical error is an important component of medical training. This qualitative study, which included postgraduate trainees from Europe and Canada, concluded that failure represents a valuable learning opportunity, but noted the importance of perceived intentions if trainees judge that their supervisors have allowed them to fail.

Healthcare Excellence Canada. 2022.

After a patient safety incident, effective discussions are critical for healing and improvement. This website houses collections of materials to support constructive communication should a failure or near-miss occur. There are two distinct sections of materials: one for established healthcare professionals, and another for patients, students, and caregivers.
Rose SC, Ashari NA, Davies JM, et al. CJEM. 2022;24:695-701.
Debriefing is used to enhance individual and team communication and to facilitate real-time learning opportunities after a critical event. This study evaluated a charge nurse-facilitated clinical debriefing program used in Emergency Departments (EDs) in Alberta, Canada. Qualitative analyses identified several themes underscoring the impact of the debriefing program – the impacts on clinical practice and patient care, impacts on psychological safety and teamwork, stress management, and the emotional acknowledgement after critical events – and barriers to debriefing.