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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 179 Results
Leitman IM, Muller D, Miller S, et al. JAMA Netw Open. 2022;5:e2244661.
The effectiveness of incident reporting systems is hindered by underreporting. This cohort study describes the characteristics of incident reports submitted by trainees in a large academic medical center. From October 2019 through December 2021, trainees submitted nearly 200 incident reports, primarily describing unprofessional interactions. Findings suggest that awareness and support for the online incident reporting system among trainees was high.
Sephien A, Reljic T, Jordan J, et al. Med Educ. 2022;Epub Oct 1.
The Accreditation Council for Graduate Medical Education (ACGME) includes work hour restrictions in its Common Program Requirements. The focus of this review is the impact of resident work hour restrictions on patient- and resident-level outcomes. Shorter shift hours were associated with some improved resident outcomes and but no association with patient outcomes.
Dehmoobad Sharifabadi A, Clarkin C, Doja A. BMJ Open. 2022;12:e063104.
Several countries have resident duty hour (RDH) restrictions and there are numerous publications examining the impact of RDH on patient safety. This study used two online discussion forums (one primarily in the United States and the other in Canada) to assess resident perceptions of RDH. Themes included its impact on residents’ education and clinician well-being, and, worryingly, discussions of not reporting RDH violations.
Boamah SA, Hamadi HY, Spaulding AC. J Patient Saf. 2022;18:e1090-e1095.
Medicare’s Hospital-Acquired Condition (HAC) Reduction Program financially incentivizes hospitals to reduce HAC rates and earlier research has shown hospitals in more diverse areas have higher odds of performing poorly. This study compares HAC reduction in Magnet and non-Magnet hospitals and examines potential racial and ethnic disparities. Similar to an earlier study, Magnet hospitals had significant improvements in methicillin-resistant Staphylococcus aureus (MRSA) rates, but not other HACs.
Windish DM, Catalanotti JS, Zaas A, et al. J Gen Intern Med. 2022;37:2650-2660.
In 2022, the Accreditation Council on Graduate Medical Education (ACGME) began requiring residency programs to provide instruction and experience in pain management for internal medicine trainees. Residency program directors were surveyed in 2019 about whether and how they provide instruction and experience to residents in safe opioid prescribing (SOP) and treatment of opioid use disorder (OUD). Most programs required didactic learning, but few required clinical experience. Given that the ACGME requirement is now in place, the researchers suggest many programs may be ill-prepared to meet the requirement.
Hoffman S. J Med Regulation. 2022;108:19-28.
Patient safety advocates have called for cognitive testing of aging clinicians and some health systems have attempted instituting such policies as part of their recredentialing program. This commentary calls for state medical boards to adopt cognitive testing as part of the recredentialling process within the confines of legal boundaries.
Lambert BL, Schiff GD. J Am Coll Clin Pharm. 2022;5:981-987.
In the wake of the criminal conviction of a nurse involved in a medical error, numerous organizations and institutions have warned of the negative impact it could have on learning and error disclosure. This commentary presents strategies to reduce the risk of criminal prosecution for pharmacists, including education of prosecutors and expert witnesses and minimization of overrides and workarounds.
Smith CJ, DesRoches SL, Street NW, et al. J Healthc Risk Manag. 2022;42:24-30.
New graduate registered nurses (NGRNs) frequently experience a knowledge-practice gap during their transition to practice. This article suggests that the gap has widened, as COVID-19 restrictions impacted pre-licensure nurses’ education, clinical training, testing, and licensure. Recommendations for improving the transition to practice include innovative academic-clinical partnerships.
Graber ML, Holmboe ES, Stanley J, et al. Diagnosis (Berl). 2022;9:166-175.
In 2019, a consensus group identified twelve competencies to improve diagnostic education. This article details next steps for incorporating competencies into interprofessional health education: 1) Developing a shared, common language for diagnosis, 2) developing the necessary content, 3) developing assessment tools, 4) promoting faculty development, and 5) spreading awareness of the need to improve education in regard to diagnosis.
Combs CA, Goffman D, Pettker CM. Am J Obstet Gynecol. 2022;226:b2-b9.
Readmission reduction as an improvement measure has been found to be problematic as a maternal safety outcome. This statement shares concerns regarding incentivizing hospitalization reductions after birth and explores the potential for patient harm due to pressures to reduce readmissions when needed.
Wojcieszak D. J Patient Saf Risk Manag. 2022;27:15-20.
Open disclosure and apology for errors is recommended in healthcare. In this study, 38 state medical boards responded to a survey regarding disclosure and apology practices after medical errors. Findings suggest that state medical boards have generally favorable views toward clinicians who disclose errors and apologize, and that these actions would not make the clinician a target for disciplinary action; respondents had less favorable views towards legislative initiatives regarding apologies and disclosure.
Zheng MY, Lui H, Patino G, et al. J Patient Saf. 2022;18:e401-e406.
California law requires adverse events that led to serious injury or death because of hospital noncompliance to be reported to the state licensing agency. These events are referred to as “immediate jeopardy.” Using publicly available data, this study analyzed all immediate jeopardy cases between 2007 and 2017. Of the 385 immediate jeopardy cases, 36.6% led to patient death, and the most common category was surgical.
Steffany M. J Healthc Risk Manag. 2022;41:31-38.
Concerns have been raised regarding the need to assess the competencies of aging physicians. This article discusses how different entities (e.g., health systems, states, and professional medical organizations) are addressing this issue through competency-based assessments, peer review, and credentialing requirements.

Joint Commission.

Sentinel events are a primary indicator of patient safety in hospitals that enable learning through reporting to the Joint Commission. This website provides access to statistics, alerts, policies and tools to assist organizations in using sentinel events for their medical error reduction efforts.

Roy CG. Yale J Biol Med. 2021;94(1):165-173. 

Delivery of safe care hinges on the competency of medical professionals. This article outlines the origins of state medical board systems in the United States and their evolving role in promoting patient safety based on IOM recommendations, including re-examination for licensure and specialty board certification, reporting, and monitoring.

Washington DC; Governmental Accountability Office; December 1, 2020. Publication GAO-21-160R.

Clinicians must receive explicit permission to work in military health system facilities. This report examined the process of monitoring military clinician practice to assure it is safe, reporting mechanisms and procedures in place for addressing concerns with providers should they arise.
White AA, Sage WM, Mazor KM, et al. Jt Comm J Qual Patient Saf. 2020;46:591-595.
This commentary discusses safety outcomes associated with late career practitioners, measuring practitioner performance, and options for practitioners with declining performance, including key features and lessons learned from early adopters of late career practitioner programs.

Philadelphia, PA: Pew Charitable Trusts; July 21, 2020.

Tracking problems with health information technology (Health IT) is an important strategy to drive improvement. This report outlines general health IT and decision support actions to inform action, and discusses the role that regulation and accreditation have for driving improvement.