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)

Clear all filter(s)

Displaying 1 - 20 of 1730 Results

Death Inside Lemuel Shattuck Hospital: A Case Study on Medical Treatment for Persons with Mental Health Disabilities.

Save to Library

Massachusetts Protection and Advocacy. Boston, MA: Disability Law Center; May 8, 2023.

Behavioral health patients present unique challenges in their care that can contribute to unintended harm. The analysis examines a delayed diagnosis, referral, and treatment of skin cancer that contributed to the death of a patient. Suggestions for improvement included conducting a root cause analysis to identify systemic problems, use of photography to track skin lesion progression, and implementation of a warm handoff process to improve staff communication.

Analysis of reported suicide safety events among veterans who received treatment through Department of Veterans Affairs-contracted community care.

Save to Library

Riblet NB, Soncrant C, Mills PD, et al. Mil Med. 2023;Epub Mar 31.

Patient suicide is a sentinel event, and suicide among veterans has gained attention. In this retrospective analysis of suicide-related events reported to the Veterans Health Administration (VHA) National Center for Patient Safety between January 2018 and June 2022, researchers found that deficiencies in mental health treatment, communication challenges, and unsafe environments were the most common contributors to suicide-related events.

Effects of a multimodal transitional care intervention in patients at high risk of readmission: the TARGET-READ randomized clinical trial.

Save to Library

Donzé JD, John G, Genné D, et al. JAMA Internal Med. 2023;Epub May 1.

Adverse events and unplanned, preventable readmissions occur in approximately 20% of patients following discharge from the hospital. This randomized clinical trial compares standard care with a multi-modal discharge intervention targeting patients at highest risk of unplanned readmission. Despite the intensity of the intervention, there was no statistical difference between that intensity and the standard of care in unplanned readmission, time to readmission, or death.

Perceived discrimination in the community pharmacy: a cross-sectional, national survey of adults.

Save to Library

Baffoe JO, Moczygemba LR, Brown CM. J Am Pharm Assoc (2003). 2023;63:518-528.

Minoritized and vulnerable people often experience delays in care due to systemic biases. This survey study examined the association between perceived discrimination at community pharmacies and foregoing or delaying picking up medications. Participants reported discrimination based on race, age, sexual orientation, ethnicity, income, and prescription insurance; those participants were more likely to delay picking up their medications. There was no association with discrimination and foregoing medications.

Nurse staffing and inpatient mortality in the English National Health Service: a retrospective longitudinal study.

Save to Library

Zaranko B, Sanford NJ, Kelly E, et al. BMJ Qual Saf. 2023;32:254-263.

Poor nurse staffing has long been recognized as a patient safety issue. This analysis of three UK National Health Service hospitals examined the differences in in-hospital deaths among different nursing team sizes and compositions. Researchers identified higher inpatient mortality with higher nurse staffing and seniority levels (i.e., more registered nurses [RNs]) but no changes in mortality related to health care support workers (HCSW). Authors surmised that HCSWs may not be a substitute for RNs.

Delays in care during the COVID-19 pandemic in the Veterans Health Administration.

Save to Library

Mills PD, Louis RP, Yackel E. J Healthc Qual. 2023;Epub Apr 11.

Changes in healthcare delivery due to the COVID-19 pandemic resulted in delays in care that can lead to patient harm. In this study using patient safety event data submitted to the VHA National Center of Patient Safety, researchers identified healthcare delays involving laboratory results, treatment and interventional procedures, and diagnosis.

Teamwork, clinical leadership skills and environmental factors that influence missed nursing care - a qualitative study on hospital wards.

Save to Library

Beiboer C, Andela R, Hafsteinsdóttir TB, et al. Nurse Educ Pract. 2023;68:103603.

Myriad factors contribute to missed nursing care including staffing, team and group norms, and teamwork. Nurses in this study described four themes that contributed to missed nursing care: teamwork in nursing wards; informal teaching and communication; influence of formal and informal leaders; and influencing factors in nurses’ work environment. Developing nurses' clinical leadership skills may improve teamwork and reduce missed care.

Floating to intensive care units: nurses' messages for instant action to promote patient safety.

Save to Library

Ahmed FR, Timmins F, Dias JM, et al. Nurs Crit Care. 2023;Epub Apr 1.

Staffing shortages are temporarily alleviated with floating or redeployed staff. This qualitative study of intensive care unit (ICU) critical care nurses and floating non-critical care nurses sought to identify the pros and cons of floating nurses, and strategies to improve patient safety. Floating nurses reported concerns surrounding unfamiliarity with the types of patients or locations of equipment. Critical care nurses reported cognitive overload with doing their routine duties plus orienting floating nurses. One recommendation to improve safety is competency-based nursing curriculum and provide floating nurses occasional training/experience in the ICU.

CUSP Implementation Training.

Save to Library

Armstrong Institute for Patient Safety and Quality.

The comprehensive unit-based safety program (CUSP) approach emphasizes improving safety culture through a continuous process of reporting and learning from errors, improving teamwork, and engaging staff at all levels in safety efforts. Available on demand and live, this session covers how to utilize CUSP, including understanding and addressing challenges to implementation. The next virtual session will be held July 18, 2023.

Improving Diagnostic Safety and Quality

Save to Library

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.

Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units

Save to Library

Perspective on Safety April 26, 2023

This piece discusses surveillance monitoring of patients in low-acuity units of the hospital to prevent failure to rescue events, its difference from high-acuity continuous monitoring, and its potential applications in other settings.

In Conversation with Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring

Drs. Susan McGrath and George Blike discuss surveillance monitoring and its challenges and opportunities.

Doctors must stop tuning out Black women. It happened to me, as a pregnant OB-GYN.

Save to Library

Gillispie-Bell V. USA Today. April 14, 2023.

Structural racism and implicit biases can lead to poor quality of care and adverse outcomes among Black women. This article describes the experience of a Black OB/GYN patient whose concerns about abdominal pain during her pregnancy were not thoroughly evaluated; clinicians also missed risk factors placing her at risk of spontaneous preterm birth.

Defining avoidable healthcare-associated harm in prisons: a mixed-method development study.

Save to Library

Keers RN, Wainwright V, McFadzean J, et al. PLOS One. 2023;18:e0282021.

Prisons present unique challenges in providing, as well as in measuring, safe patient care. This article describes structures and processes within prison systems that may contribute to avoidable harm, such as limited staffing and security to travel to healthcare appointments. The result is a two-tier definition taking into consideration the unique context of prison healthcare.

Linking patient safety climate with missed nursing care in labor and delivery units: findings from the LaborRNs survey.

Save to Library

Zhong J, Simpson KR, Spetz J, et al. J Patient Saf. 2023;19:166-172.

Missed nursing care is a key indicator of patient safety and has been linked to safety climate. Survey responses from 3,429 labor and delivery nurses from 253 hospitals across the United States found an average of 11 of 25 aspects of essential nursing care were occasionally, frequently, or always missed. Higher perceived safety climate was associated with less missed care. The authors discuss the importance of strategies to reduce missed care, such as adequate nurse staffing, ensuring nonpunitive responses to errors, and promoting open communication.

Potential uses of AI for perioperative nursing handoffs: a qualitative study.

Save to Library

King CR, Shambe A, Abraham J. JAMIA Open. 2023;6:ooaf015.

Handoffs and transitions of care represent a vulnerable time for patients as important information must be shared and understood by multiple people. This study focuses on postoperative nurse handoffs, specifically regarding situational awareness and anticipatory guidance, and the role artificial intelligence (AI) could play in improving handoffs. Five themes were uncovered, including the importance of situational awareness and associated barriers, how AI could address those barriers, and how AI could result in new/additional barriers.

An evidence synthesis on perioperative handoffs: a call for balanced sociotechnical solutions.

Save to Library

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.

Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue.

Save to Library

WebM&M Case March 29, 2023

This case describes a 13-year-old girl who presented to several health care providers with typical symptoms, physical signs, and early laboratory findings suggestive of adrenal insufficiency (AI) yet the diagnosis was delayed for several months due to diagnostic biases. After she suffered a sudden cardiac arrest during a visit to her local emergency department and was airlifted to a tertiary care facility, she was found to be in adrenal crisis secondary to Addison’s disease.

Anesthesiology patient handoff education interventions: a systematic review.

Save to Library

Riesenberg LA, Davis R, Heng A, et al. Jt Comm J Qual Patient Saf. 2022;Epub Dec 15.

Anesthesiologists frequently hand off care of complex, often unstable patients, which can introduce patient safety risks. This systematic review examined the education components of studies seeking to improve anesthesiology handoffs. The authors identified marked heterogeneity in the use of established curriculum development best practices and concluded that more than half of the medical education interventions were of low quality. The authors identify challenges that could be addressed to improve future educational interventions.

Evaluating patient identification practices during intrahospital transfers: a human factors approach.

Save to Library

Suclupe S, Kitchin J, Sivalingam R, et al. J Patient Saf. 2023;19:117-127.

Patient identification mistakes can have serious consequences. Using the Systems Engineering for Patient Safety (SEIPS) framework, this qualitative study explored systems factors contributing to patient identification errors during intrahospital transfers. The authors found that patient identification was not completed according to hospital policy during any of the 60 observed patient transfer handoffs. Miscommunication and lack of key patient information were common factors contributing to identification errors.

Frequency of medication administration timing error in hospitals: a systematic review.

Save to Library

Pullam T, Russell CL, White-Lewis S. J Nurs Care Qual. 2023;38:126-133.

Medication timing errors can lead to too-frequent or missed doses of medications and cause patient harm. This systematic review including 23 articles found that medication administration timing errors (defined in the majority of studies as administration greater than 60 minutes before or after the scheduled time) occur in up to 72.6% of medication administration errors.

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 Case

Continue as a Guest

Continue Logged In

Submit Your Case

Continue as a Guest

Already have a PSNet

Account?

New Users

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