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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 3627 Results
International Association of Risk Management in Medicine. March 16-17, 2024, The University of Tokyo, Medical Campus.
This conference -- to be presented in tandem with the 11th World Congress on Clinical Safety--will provide oral and poster presentations related to the theme of "Journey to the New World of Healthcare Safety". Topics to be covered include infection control, psychological safety and healthcare worker safety. A post-conference on-demand viewing option will be available.
Montalmant KE, Ettinger AK. J Racial Ethn Health Disparities. 2023;Epub Nov 13.
The increased risk of maternal morbidity and mortality among Black women in the United States is a patient safety and public health crisis. This literature review of 42 articles highlights the importance of cultural competence and disparities training for obstetric providers to reduce maternal mortality and morbidity among Black women. The authors also highlight the need for increased awareness regarding the increased risk of cardiovascular diseases among pregnant Black women.
Bushuven S, Bentele M, Bentele S, et al. J Med Syst. 2023;47:123.
ChatGPT has emerged as a potentially useful tool for clinicians and the public in obtaining heath advice and diagnosis. In this study, six iterations of 22 pediatric emergency vignettes were entered into ChatGPT (total of 132 scenarios) to assess diagnostic accuracy, emergency call advice, and validity of advice given. ChatGPT correctly recommended contacting medical professionals in all cases but only advised calling emergency medical services (EMS) or 911 in 12 of the 22 scenarios. The correct diagnosis was made in 94% of cases, consistent with other research into ChatGPT. Considerably more research is required before ChatGPT could be recommended for diagnostic advice.

Sepsis Alliance. December 14, 2023, 12:00 - 3:30 PM (eastern). 

Healthcare-associated infections (HAIs) are a pervasive and preventable contributor to sepsis and patient harm. This session will discuss areas of focus in the HAI spectrum such as central line–associated bloodstream infections, or CLABSIs. The presenters will review prevention strategies and documentation to support their use in the care environment.
WebM&M Case November 30, 2023

A 67-year-old man with well-controlled type 2 diabetes mellitus underwent elective cardiac resynchronization and defibrillator device (CRT-D) implantation. The procedure was successful and he was discharged the next day with instructions to resume his prior medications, including empagliflozin. He presented to the emergency department the following day where he was diagnosed with euglycemic diabetic ketoacidosis (eDKA) and he was transferred to the intensive care unit (ICU) for insulin infusion.

Park J, Jeon H, Choi EK. J Adv Nurs. 2023;Epub Nov 10.
Digital health tools are increasingly used to support the delivery of safe healthcare. This scoping review characterized 13 articles exploring the use of digital interventions intended to support patient safety among pediatric patients and their parents. Interventions were commonly delivered through mobile applications, web-based technologies, computer kiosks, and electronic health records, and focused on patient safety event prevention and risk management.
Weaver MD, Barger LK, Sullivan JP, et al. Sleep Health. 2023;Epub Nov 6.
Current Accreditation Council for Graduate Medical Education (ACGME) duty hour regulations limit resident work hours (no more than 80 hours per week or 24-28 consecutive hours on duty) in an effort to improve both resident and patient safety. This nationally representative survey found that over 90% of US adults disagree with the current duty hour policies, with 66% of respondents supporting additional limits on duty hours (to no more than 40 hours per week or 12 consecutive hours).
Institute for Healthcare Improvement. March 7–8 2024, 12:00-4:00 PM (eastern).
This online class prepares individuals to apply for the Institute for Healthcare Improvement patient safety certification program. The on-demand or live sessions cover key patient safety concepts to enhance participants' knowledge about safety culture, systems thinking, leadership, risk identification and analysis, information technology, and human factors. 
Perspective on Safety November 27, 2023

This piece discusses how undergraduate professional nursing education integrates the topic of patient safety into classroom and clinical instruction, and how this affects patient safety as a whole.

This piece discusses how undergraduate professional nursing education integrates the topic of patient safety into classroom and clinical instruction, and how this affects patient safety as a whole.

Joan Stanley

Joan Stanley is the chief academic officer at the American Association of Colleges of Nursing (AACN).  We spoke to her about how undergraduate professional nursing education integrates the topic of patient safety into classroom and clinical instruction, and how this affects patient safety as a whole.

Institute for Healthcare Improvement. March 6 - May 20, 2024.
Burnout among health care workers negatively affects system improvement. This webinar series will highlight strategies to establish a healthy work environment that strengthens teamwork, staff engagement, and resilience. Instructors include Dr. Donald Berwick and Derek Feeley.

ISMP Medication Safety Alert! Acute Care. November 2, 2023;28(22):1-4.

Intravenous (IV) push medication administration is a primary therapeutic approach where process gaps can result in harm. This article examines existent presence of recognized safe practice education in close to 200 surveyed nursing programs to assess the teaching of standardized practice behaviors at the student level and recommend strategies to embed IV safety into instruction efforts.
Krogh TB, Mielke-Christensen A, Madsen MD, et al. BMC Med Educ. 2023;23:786.
Medical trainees suffer from "second victim syndrome" (SVS) at rates similar to practicing healthcare professionals but they may not have the same resources to recover. This study of medical students' experiences describes the usual triggers of SVS such as patient harm, but also from negative responses by supervising physicians. Formal instruction and open discussion of SVS can support students' well-being and recovery.
Mohamed I, Hom GL, Jiang S, et al. Acad Radiol. 2023;Epub Sep 22.
Psychological safety is an important principle in identifying problems and improving patient outcomes. This narrative review highlights five best practices to foster psychological safety in radiology residencies – (1) establish clear goals and educational strategies, (2) build a formal mentoring program, (3) assess psychological safety, (4) advocate for radiologists as educators, and (5) support non-radiology staff. Although the review focuses on radiology residency programs, these strategies can be adapted to any residency program.
Grace MA, O'Malley R. Simul Healthc. . 2023;Epub Sep 19.
In situ simulation can reveal latent safety threats before they cause harm. This review identified 15 studies of in situ simulations conducted in the emergency department including simulations conducted prior to opening new facilities and to address emerging COVID-19 concerns. The most commonly identified safety threats were related to equipment and team communication.
Clarke-Romain B. Emerg Nurse. 2023;Epub Sep 19.
Delays in raising concerns in acute or emergency care can have tragic consequences. This commentary uses a case study to highlight barriers to speaking up and evidence-based tools nurses can use such as the CUS Tool and two-challenge rule. Training all healthcare staff in communication techniques can encourage speaking up and respectful responses.
Jt Comm J Qual Patient Saf. 2023;Epub Oct 18.
Surgical fires are a rare yet potentially harmful event for both patients and care teams. The alert provides reduction guidance for organizations to mitigate conditions that enable surgical fires and suggests tactics to improve communication as a primary strategy for preventing this potentially catastrophic accident in operating rooms.

Armstrong Institute for Patient Safety and Quality, Baltimore, MD. April 17-18, 2024.

Human factors engineering (HFE) is a primary strategy for advancing safety in health care. This virtual workshop will introduce HFE methods and discuss how they can be used to reduce risk through design improvements in a variety of process and interpersonal situations.

Institute for Healthcare Improvement. March 13 - April 23, 2024.

Root cause analysis (RCA) is a widely recognized retrospective strategy for learning from failure that is challenging to implement. This series of webinars will feature an innovative approach to RCA that expands on the concept to facilitate its use in incident investigations. Instructors for the series will include Dr. Terry Fairbanks and Dr. Tejal K. Gandhi.
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 January 16, 2024.