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

Clear all filter(s)

Displaying 1 - 20 of 2263 Results

Impact of pharmacist-led admission medication reconciliation on patient outcomes in a large health system.

Save to Library

Kramer JS, Hayley Burgess L, Warren C, et al. J Patient Saf Risk Manag. 2023;Epub Aug 27.

Obtaining a best possible medication history (BPM) is an important component of successful medication reconciliation programs. This study compared the impact of a pharmacy-led medication reconciliation program including BPMH on adverse drug events (ADEs) and complications among high-risk, complex patients across 16 hospitals. In the six months following implementation, 80,000 reconciliations were completed and nearly 40% required additional medication follow-up and/or clarification. Researchers identified a statistically significant decrease in both ADEs and complications after implementation.

Radiographers' experience of preventing patient safety incidents in the context of radiological examinations.

Save to Library

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.

Work system barriers and facilitators of a team health information technology.

Save to Library

Hose B-Z, Carayon P, Hoonakker PLT, et al. Appl Ergon. 2023;113:104105.

Health information technology (IT) usability continues to be a source of patient harm. This study describes the perspectives of a variety of pediatric trauma team members (e.g., pediatric emergency medicine attending, surgical technician, pediatric intensive care unit attending) on the usability of a potential team health IT care transition tool. Numerous barriers and facilitators were identified and varied across department and role.

Long-term sustainability and adaptation of I-PASS handovers.

Save to Library

Ryan SL, Logan M, Liu X, et al. Jt Comm J Qual Patient Saf. 2023;Epub Jul 31.

I-PASS is a structured tool to improve handoffs and communication between clinicians and promote patient safety. This study examined I-PASS implementation practices over a six-year period in 10 departments at one large academic medical center. Researchers found that most clinical services successfully implemented I-PASS and those using I-PASS conducted the most efficient handovers.

Handling polypharmacy--a qualitative study using focus group interviews with older patients, their relatives, and healthcare professionals.

Save to Library

Mikkelsen TH, Søndergaard J, Kjaer NK, et al. BMC Geriatr. 2023;23:477.

Older adults taking 5 or more medications daily (i.e., polypharmacy) face numerous challenges to taking them safely. In this study, patients, caregivers, and clinicians describe methods to taking medications safely, difficulties they face, and ways prescribers and pharmacists can assist patients. Medication reviews, a common strategy to ensure safe polypharmacy, were requested by patients to clear up confusion around generics, timing, limitations, and side effects.

Pediatric Diagnostic Safety: State of the Science and Future Directions.

Save to Library

Grubenhoff JA, Cifra CL, Marshall T, et al. Rockville, MD: Agency for Healthcare Research and Quality; September 2023. AHRQ Publication No. 23-0040-5-EF.

Unique challenges accompany efforts to study and reduce diagnostic error in children. This issue brief discusses addressing obstacles associated with testing and care access limitations that affect diagnosis across a variety of pediatric care environments. It also provides recommendations for building capacity to advance pediatric diagnostic safety. This issue brief is part of a series on diagnostic safety.

How does robotic-assisted surgery change OR safety culture?

Save to Library

AMA J Ethics. 2023;25:E615-E623.

The safety culture of an operating room is known to affect teamwork and patient outcome. This article discusses the unique characteristics of robotic-assisted surgical practice and approaches teams and organizations can take to enhance communication that supports a safe care culture.

Video review of simulated pediatric cardiac arrest to identify errors/latent safety threats: a mixed methods study.

Save to Library

Garcia-Jorda D, Nikitovic D, Gilfoyle E. Simul Healthc. 2023;18:232-239.

Simulation trainings are widely used to identify safety threats and improve processes. By analyzing video recordings of pediatric cardiac arrest simulations, researchers were able to identify 5 main areas of errors: clinical, planning and execution, communication, distraction, and knowledge/training. Investigating the root causes of these errors can result in improved trainings and, thus, improved patient outcomes.

Intraoperative communications between pathologists and surgeons: do we understand each other?

Save to Library

Wiggett A, Fischer G. Arch Pathol Lab Med. 2023;147:933-939.

Miscommunication between pathologists and surgeons can lead to significant patient harm. This study identified multiple discrepancies between pathologist-listed diagnoses included in intraoperative consult notes compared to surgeon-dictated operative notes. Discrepancies were most common in multipart cases and those involving deferrals.

TeamSTEPPS Refresher Course.

Save to Library

AHA Training. October 3-24, 2023. Tuesdays 2:00 PM - 3:30 PM (eastern).

Revisiting concept foundations is an important strategy to learn from experience and energize project participants. This virtual series will prepare participants to begin the implementation of the TeamSTEPPS program at their institutions and draw from the knowledge of others to make adjustments as needed to support teamwork training efforts.

Virtual Nursing: Improving Patient Care and Meeting Workforce Challenges

Save to Library

Perspective on Safety August 30, 2023

This piece discusses virtual nursing, an approach to care that incorporates an advanced practice nurse into hospital-based patient care through telehealth. Virtual nursing increases patient safety and may enable expert nurses to continue to meet patient needs in future staffing shortages.

In Conversation with Kathleen Sanford and Sue Schuelke about Virtual Nursing

Editor’s note: Kathleen Sanford is the chief nursing officer and an executive vice president at CommonSpirit. Sue Schuelke is an assistant professor at the College of Nursing–Lincoln Division, University of Nebraska Medical Center. They have pioneered and tested a new model of nursing care that utilizes technology to add experienced expert nurses to care teams, called Virtual Nursing.

Anesthesia Risk Alert program: a proactive safety initiative.

Save to Library

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.

Prolonged DKA in Pregnancy: A Case of Communication Breakdown.

Save to Library

WebM&M Case August 30, 2023

A 31-year-old pregnant patient with type 1 diabetes on an insulin pump was hospitalized for euglycemic diabetic ketoacidosis (DKA). She was treated for dehydration and vomiting, but not aggressively enough, and her metabolic acidosis worsened over several days. The primary team hesitated to prescribe medications safe in pregnancy and delayed reaching out to the Maternal Fetal Medicine (MFM) consultant, who made recommendations but did not ensure that the primary team received and understood the information.

Barriers and facilitators to implementing interventions for reducing avoidable hospital readmission: systematic review of qualitative studies.

Save to Library

Fu BQ, Zhong CCW, Wong CHL, et al. Int J Health Policy Manag. 2023;12:7089.

Peri-discharge interventions aim to reduce potential adverse events that can arise during and after hospital discharge. This systematic review of 13 qualitative studies identified common barriers and facilitators to implementing peri-discharge interventions. Frequently cited barriers included limited resources, poor team communication, and complicated intervention processes; common facilitators included leadership support, a positive organizational culture, and financial penalties.

Exploring the impact of safety culture on incident reporting: lessons learned from machine learning analysis of NHS England staff survey and incident data.

Save to Library

Kaya GK, Ustebay S, Nixon J, et al. Safety Sci. 2023;166:106260.

Voluntary incident reporting rates may be an indicator of organizational safety culture. Using different machine learning algorithms, this study found that several components of safety culture – compassionate culture, violence and harassment, and work pressure – have a significant impact on predicting incident reporting behavior.

Healthcare fragmentation, multimorbidity, potentially inappropriate medication, and mortality: a Danish nationwide cohort study.

Save to Library

Prior A, Vestergaard CH, Vedsted P, et al. BMC Med. 2023;21:305.

System weaknesses (e.g., resource availability, deficiencies in care coordination) threaten patient safety. This population-based cohort study including 4.7 million Danish adults who interacted with primary or hospital care in 2018, found that indicators of care fragmentation (e.g., higher numbers of involved clinicians, more transitions between providers) increased with patient morbidity level. The researchers found that higher levels of care fragmentation were associated with adverse outcomes, including potentially inappropriate prescribing and mortality.

Clinicians' insights on emergency department boarding: an explanatory mixed methods study evaluating patient care and clinician well-being.

Save to Library

Loke DE, Green KA, Wessling EG, et al. Jt Comm J Qual Patient Saf. 2023;Epub Jul 2.

Quantitative studies have demonstrated that emergency department (ED) overcrowding and patient boarding contribute to adverse events. This study includes both qualitative and quantitative methods to understand how ED clinicians view the impact of boarding on their own well-being as well as patient safety. Key themes include clinician dissatisfaction and burnout, and high rates of verbal and physical abuse from boarding patients. Possible solutions included improved standardization of care, proactive planning, and culture change hospital-wide.

Cognitive biases and moral characteristics of healthcare workers and their treatment approach for persons with advanced dementia in acute care settings.

Save to Library

Erel M, Marcus E-L, DeKeyser Ganz F. Front Med (Lausanne). 2023;10:1145142.

Cognitive biases can influence treatment approach at the end of life. The goal of this study was to determine whether treatment approaches (e.g., palliative care to aggressive treatment) were associated with clinician cognitive biases in acute care settings for patients with advanced dementia and comorbidities. Representativeness, availability, and anchoring biases were associated with treatment approach in this hypothetical patient case; moral characteristics of the clinician were not associated with treatment approach.

Patient handoffs and multi-specialty trainee perspectives across an institution: informing recommendations for health systems and an expanded conceptual framework for handoffs.

Save to Library

Williams SR, Sebok-Syer SS, Caretta-Weyer H, et al. BMC Med Educ. 2023;23:434.

Standardizing handoff training in residency programs can lead to safer, more effective handoffs. Researchers surveyed a sample of 687 residents and fellows from over 30 specialties about handoff training perspectives. Participants reported wide variability in handoff content and identified important aspects of handoff training (critical handoff elements, the impact of systems-level factors, impact of the handoff on providers and patients, professional duty, and addressing blame or guilt related to poor handoff experiences).

TeamSTEPPS Master Training Course.

Save to Library

Armstrong Institute for Patient Safety and Quality. October 3 and 5, 2023.

Team training programs seek to improve communication and coordination among team members to reduce the potential for medical error. This virtual workshop will train participants to design, implement, and evaluate team training programs in their organizations based on the TeamSTEPPS model.

The PSNet Collection: All Content

Search All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

The PSNet Collection: All Content

Search All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site