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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 2078 Results
Tawfik DS, Adair KC, Palassof S, et al. Jt Comm J Qual Patient Saf. 2022;Epub Dec 23.
Leadership across all levels of a health system plays an important role in patient safety. In this study, researchers administered the Safety, Communication, Operational, Reliability, and Engagement (SCORE) survey to 31 Midwestern hospitals to evaluate how leadership behaviors influenced burnout, safety culture, and engagement. Findings indicate that local leadership behaviors are strongly associated with healthcare worker burnout, safety climate, teamwork climate, workload, and intentions to leave the job.
Weaver SH, de Cordova PB, Ravichandran A, et al. J Nurs Care Qual. 2022;Epub Dec 7.
Nurse work environment has been linked to perceived safety culture and job satisfaction. This cross-sectional survey of licensed practical nurses (LPNs) in New Jersey found lower job satisfaction and perceived patient safety culture among LPNs working in nursing homes compared to LPNs working in other settings.
Abrams R, Conolly A, Rowland E, et al. J Adv Nurs. 2023;Epub Jan 16.
Speaking up about safety concerns is an important component of safety culture. In this study, nurses in a variety of fields shared their experiences with speaking up during the COVID-19 pandemic. Three themes emerged: the ability to speak up or not, anticipated consequences of speaking up, and responses, or lack thereof, from managers.
Gillissen A, Kochanek T, Zupanic M, et al. Diagnosis (Berl). 2022;Epub Nov 9.
Medical students do not always feel competent when it comes to patient safety concepts. In this study of German medical students, most understood the importance of patient safety, though few could identify concrete patient safety topics, such as near miss events or conditions that contribute to errors. Incorporating patient safety formally into medical education could improve students’ competence in these concepts.
Świtalski J, Wnuk K, Tatara T, et al. Int J Environ Res Public Health. 2022;19:15354.
Improving patient safety in long-term care facilities is an ongoing challenge. This systematic review identified three types of interventions that can improve safety in long-term care facilities – (1) promoting safety culture, (2) reducing occupational stress and burnout, and (3) increasing medication safety.
Lucas SR, Pollak E, Makowski C. J Healthc Risk Manag. 2022;Epub Dec 4.
Medical errors that receive widespread media attention frequently spur health systems to reexamine their own culture and practices to prevent similar errors. This commentary describes one health system’s effort to identify and improve the system factors (systems, processes, technology) involved in the error. The action plan proposed by this project includes ensuring a just culture so staff feel empowered to report errors and near-misses; regularly review and improve medication delivery systems; build resilient medication delivery systems; and, establish methods of investigations.
Pado K, Fraus K, Mulhem E, et al. J Clin Psychol Med Settings. 2022;Epub Dec 12.
Medical errors may lead to feelings of distress for clinicians, but these errors can also be an opportunity for growth. This study used the Second Victim Experience and Support Tool (SVEST) and the Posttraumatic Growth Inventory to assess the extent, if any, of growth following a medical mishap. Rumination and the impact of the medical mishap were associated with distress among both physicians and nurses. The impact of the event was associated with growth in nurses, but no factor was associated with growth in physicians.
Mahat S, Rafferty AM, Vehviläinen-Julkunen K, et al. BMC Health Serv Res. 2022;22:1474.
Healthcare staff who are involved in a medical error often experience emotional distress. Using qualitative methods and text mining of medication error incident reports, researchers in this study identified the negative emotions experienced by healthcare staff after a medication error (e.g., fear, guilt, sadness) and perceptions regarding how superiors and colleagues effectively responded to the events (e.g., reassurance, support, and guidance).
Feldman N, Volz N, Snow T, et al. J Patient Saf Risk Manag. 2022;27:229-233.
Research with medical and surgical residents has shown they are frequently reluctant to speak up about safety and unprofessional behavior they observe. This study asked emergency medicine residents about their speaking up behaviors. Using the Speaking Up Climate (SUC)-Safe and SUC-Prof surveys, residents reported generally neutral responses to speaking up, more favorable than their medical and surgical counterparts. In line with other studies, residents were more likely to speak up about patient safety than about unprofessional behaviors.
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.
Institute for Safe Medication Practices. February 1-2, 2023.
This virtual workshop will explore tactics to ensure medication safety, including strategic planning, risk assessment, and Just Culture principles.
Crunden EA, Worsley PR, Coleman SB, et al. Int J Nurs Stud. 2022;135:104326.
Hospital-acquired pressure ulcers, categorized as a never event, are underreported, particularly when related to medical devices. Interviews with experts in hospital-acquired pressure ulcers revealed four domains related to reporting: 1) individual health professional factors, 2) professional interactions, 3) incentives and resources, and 4) capacity for organizational change. Teamwork, openness, and feedback were seen as the main facilitators to reporting, and financial consequences was a contributing barrier.
Hunt J, Gammon J, Williams S, et al. BMC Health Serv Res. 2022;22:1446.
Isolation for infection prevention and control may result in unintended consequences for patient safety. Using focus groups at two hospitals, this study explored healthcare staff understanding of infection prevention practices and patient safety culture within insolation settings. Thematic analysis highlights the importance of engaged leadership, appropriate staffing, teamwork, and prioritization of patient-centered care in achieving a culture of safety and improvements in infection prevention.

Hare R, Tyler ER, Tapia A, Fan L, et al. Rockville, MD: Agency for Healthcare Research and Quality; November 2022. AHRQ Publication No. 22(23)-0008.

The AHRQ Surveys on Patient Safety Culture™ (SOPS®) Hospital Survey Hospital Survey on Patient Safety Culture ask health care providers and staff about the extent to which their organizational culture supports patient safety. The SOPS Workplace Safety Supplemental Item Set for Hospitals was designed for use in conjunction with the AHRQ Hospital Survey to help hospitals assess the extent to which their organization’s culture supports workplace safety for providers and staff. This data analysis found “Protection From Workplace Hazards” as the highest-scoring composite measure and “Addressing Workplace Aggression From Patients or Visitors” as the lowest-scoring composite measure. An average of 34% of healthcare providers and staff experienced symptoms of “Work Stress/Burnout” which represents a 4-percentage point increase from the 2021 pilot study results.
Kim K-A, Lee J, Kim D, et al. BMC Health Serv Res. 2022;22:1376.
Safety culture has been shown to be associated with nursing home quality indicators such as discharge to community and injuries related to falls and catheters. Numerous surveys exist to measure safety culture. This review identified seven measurement tools, and the most frequently used tool was the Nursing Home Survey on Patient Safety Culture. The Hospital Survey on Patient Safety Culture, Safety Attitudes Questionnaire, and Modified Stanford Patient Safety Culture Survey Instrument were also used.
Kim S, Lynn MR, Baernholdt MB, et al. J Nurs Care Qual. 2022;38:11-18.
In response to concerns about workplace violence (WPV) directed at healthcare workers in the US, the Joint Commission issued a Sentinel Event Alert and recommendations to increase organizational awareness of this risk. This study evaluated the effect of one of those recommendations, a WPV-reporting culture, on nurses’ burnout and patient safety. As anticipated, WPV increased nurse burnout, but unexpectedly, a strong WPV-reporting culture also increased the negative effect of WPV on burnout.

Arna D, ed. Curr Opin Anaesthesiol. 2022;35(6):710-737.

Safety challenges in anesthesiology and perioperative care are high-risk situations. This segment of a reoccurring special section covers strategies for improvement such as use of databases to monitor safety, expansion of safety improvement efforts to perioperative care, and cognitive aid use enhancement.
Yount N, Edelman S, Sorra J, et al. Rockville, MD: Agency for Healthcare Research and Quality; November 2022. AHRQ Publication No. 23-0011.
Improving the culture of safety within health care is an essential component of preventing or reducing errors. Designed for users of the AHRQ safety culture surveys, this updated tool will help organizations develop an action plan and proactively discuss potential barriers to safety culture improvement efforts and how to address them. The revision is structured around a 3-step process that focuses on areas to improve, initiative planning, and plan communication. The kit now includes an action plan template.
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.