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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 563 Results
Wallin A, Ringdal M, Ahlberg K, et al. Scand J Caring Sci. 2023;37:414-423.
Numerous factors can hinder safe radiology practices, such as communication failures and image interpretation errors. Based on semi-structured interviews with 17 radiologists in Sweden, this study identified 20 themes at the individual-, organization-, technology-, task-and environment-levels describing factors supporting patient safety in radiology. Factors described by participants included the use of standardized tools and work routines (e.g., checklists), handoffs, and incident reporting systems.
Lee B, Marhalik-Helms J, Penzi L. Jt Comm J Qual Patient Saf. 2023;49:441-449.
Perioperative and anesthesia care present unique patient safety challenges. This article describes the development and implementation of the Anesthesia Risk Alert (ARA) program, which promotes collaborative clinical decision-making and recommends risk mitigation strategies to address specific high-risk clinical scenarios. Since implementation began in 2019, ARA compliance has exceeded 90% and has reduced the rate of adverse events among certain high-risk patients, such as those with a high body mass index.
Webster CS, Mahajan R, Weller JM. Br J Anaesth. 2023;131:397-406.
Systems involving people, tools, technology, and work environments must interact effectively to ensure the delivery of safe, effective care. This narrative review uses a sociotechnical perspective to explore the inter-relationship between technology and the human work environment during the delivery of anesthesia in the operating room. The authors discuss systems-level approaches, such as such as surgical safety checklists, as well as the role of resilience and new technologies (i.e., artificial intelligence).
Patient Safety Innovation July 31, 2023

Concern over patient safety issues associated with inadequate tracking of test results has grown over the last decade, as it can lead to delays in the recognition of abnormal test results and the absence of a tracking system to ensure short-term patient follow-up.1,2 Missed abnormal tests and the lack of necessary clinical follow-up can lead to a late diagnosis.

WebM&M Case July 31, 2023

A 50-year-old unhoused patient presented to the Emergency Department (ED) for evaluation of abdominal pain, reportedly one day after swallowing multiple sharp objects. Based on the radiologic finding of an open safety pin or paper clip in the distal stomach, he was appropriately scheduled for urgent esophagogastroduodenoscopy and ordered to remain NPO (nothing by mouth) to reduce the risk of aspirating gastric contents.

Arredondo Montero J, Bardají Pascual C. Clin Pediatr (Phila). 2023;Epub May 29.
Human factors strategies are increasingly applied in health care to mitigate the impact of human error in medicine. This article discusses the use of checklists to systematize anesthesia and reduce risk in pediatric surgery.
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.
Turley N, Elam M, Brindle ME. JAMA Netw Open. 2023;6:e2317183.
The WHO Surgical Safety Checklist (SSC) has been widely implemented in surgical settings across the globe. This qualitative study examined surgical team member experience regarding modifications to the SSC in hospitals in high-income countries. Respondents supported routine review of SSCs to ensure they are modified and updated to address local issues and standards of practice and noted that the modification process can improve team cohesion and SSC buy-in.
WebM&M Case June 14, 2023

A 63-year-old man presented from a skilled nursing facility (SNF) with shortness of breath and was treated for mild heart failure exacerbation. An echocardiogram was performed but results were pending on discharge, with anticipation that the patient’s primary care provider would follow up the results. Two weeks later, the patient was readmitted from the SNF and was found to have endocarditis and infected pacemaker wires.

Patient Safety Innovation May 31, 2023

Patient falls in hospitals are common and debilitating adverse events that persist despite decades of effort to minimize them. Improving communication across the assessing nurse, care team, patient, and patient’s most involved friends and family may strengthen fall prevention efforts. A team at Brigham and Women’s Hospital in Boston, Massachusetts, sought to develop a standardized fall prevention program that centered around improved communication and patient and family engagement.

Staal J, Zegers R, Caljouw-Vos J, et al. Diagnosis (Berl). 2022;10:121-129.
Checklists are increasingly used to support clinical and diagnostic reasoning processes. This study examined the impact of a checklist on electrocardiogram interpretation in 42 first-year general practice residents. Findings indicate that the checklist reduced the time to diagnosis but did not affect accuracy or confidence.
Gefter WB, Hatabu H. Chest. 2023;163:634-649.
Cognitive bias, fatigue, and shift work can increase diagnostic errors in radiology. This commentary recommends strategies to reduce these errors in diagnostic chest radiography, including checklists and improved technology (e.g., software, artificial intelligence). In addition, the authors offer practical step-by-step recommendations and a sample checklist to assist radiologists in avoiding diagnostic errors.
Pati AB, Mishra TS, Chappity P, et al. Jt Comm J Qual Patient Saf. 2023;49:572-577.
The World Health Organization (WHO) Surgical Safety Checklist is widely used, but implementation challenges remain. This article describes the development of an electronic version of the surgical safety checklist adapted for use on a personal device, and compared its use against the traditional paper-based checklist. The electronic checklist had 100% use (compared to 98% for the traditional checklist) and significantly higher frequency of completion (100% vs. 27%).
Pugh S, Chan F, Han S, et al. J Nurs Adm. 2023;53:292-298.
The COVID-19 pandemic dramatically impacted the delivery of nursing care. This retrospective analysis examined the impact of a bedside checklist and nursing-led intervention bundle (“Nursing Back to Basics” or NB2B bundle) among patients hospitalized with COVID-19 at one academic hospital in New York City. The NB2B bundle, implemented with a bedside checklist, included five evidence-based interventions. Between March and April 2020, the NB2B intervention showed a 12% reduction in mortality due to COVID-19 compared with usual care.
May 4, 2023
The implementation of effective patient safety initiatives is challenging due to the complexity of the health care environment. This curated library shares resources summarizing overarching ideas and strategies that can aid in successful program execution, establishment, and sustainability.
Perspective on Safety April 26, 2023

Throughout 2022, AHRQ PSNet has shared research that elucidates the complex nature of misdiagnosis and diagnostic safety. This Year in Review explores recent work in diagnostic safety and ways that greater safety may be promoted using tools developed to improve diagnostic practices.

Throughout 2022, AHRQ PSNet has shared research that elucidates the complex nature of misdiagnosis and diagnostic safety. This Year in Review explores recent work in diagnostic safety and ways that greater safety may be promoted using tools developed to improve diagnostic practices.

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.
Abraham J, Duffy C, Kandasamy M, et al. Int J Med Inform. 2023;174:105038.
Multiple handoffs occur during the perioperative period, each presenting an opportunity for miscommunication and patient harm. This review uses the Systems Engineering Initiative for Patient Safety (SEIPS) framework to describe the barriers and enablers for improving staff communication pre-, intra-, and post-operative handoffs. Structured hand-offs, checklists, protocols, and interprofessional teamwork were cited as enablers for improved communication.
Wahr JA. UpToDate. March 31, 2023.
The operating room is a high-risk environment influenced by culture, teamwork, and task complexity. This review provides an overview of patient safety challenges in the operating room and highlights key approaches for improvement such as system engineering, collaboration, and checklists.
WebM&M Case March 15, 2023

A 48-year-old woman was placed under general anesthesia with a laryngeal mask. The anesthesiologist was distracted briefly to sign for opioid drugs in a register, and during this time, the end-tidal carbon dioxide alarm sounded. Attempts to manually ventilate the patient were unsuccessful. The anesthesiologist asked for suxamethonium (succinylcholine) but the drug refrigerator was broken and the medication had to be retrieved from another room.