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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 5116 Results

Järvinen TLN, Rickert J, Lee MJ, et al. Clin Orthop Relat Res. 2013-2023.

This quarterly commentary explores a wide range of subjects associated with patient safety, such as the impact of disruptive behavior on teams, the value of apologies, and safety challenges due to COVID-19. Older materials are available online for free.
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.
Woodier N, Burnett C, Moppett I. J Patient Saf. 2022;19:42-47.
Reporting and learning from adverse events is a core patient safety activity. Findings from this scoping review indicate limited evidence demonstrating that reporting and learning from near-miss events improves patient safety. The authors suggest that future research further explore this relationship and establish the effectiveness of system-level actions to avoid near misses.
Kramer DB, Yeh RW. JAMA. 2023;329:136-143.
The Food and Drug Administration (FDA) plays an important role in ensuring the safety of medical devices. In this cross-sectional study, researchers identified a high risk of future Class 1 FDA recall (the most serious recall designation, indicating serious risks to patient safety) among previously authorized devices (predicates) with prior Class 1 recalls.

Collaborative for Accountability and Improvement Policy Committee. Seattle, WA: University of Washington; 2022

Communication and resolution programs (CRP) show promise for improving patient and clinician communication after a harmful preventable adverse event. This tool provides a framework for organizational messaging on CRPs for patients and families.

Institute for Healthcare Improvement. Mar 14 - May 16, 2023.

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.
Aubin DL, Soprovich A, Diaz Carvallo F, et al. BMJ Open Qual. 2022;11:e002004.
Healthcare workers (HCW) and patients can experience negative psychological impacts following medical error; the negative impact can be compounded when workers and patients are prevented from processing the error. This study explored interactions between patients/families and HCWs following a medical error, highlighting barriers to communication, as well as the need for training and peer support for HCWs. Importantly, HCW and patients/families expressed feeling empathy towards the other and stressed that open communication can lead to healing for some.
Pollock BD, Dykhoff HJ, Breeher LE, et al. Mayo Clin Proc Innov Qual Outcomes. 2023;7:51-57.
The COVID-19 pandemic dramatically impacted healthcare delivery and raised concerns about exacerbating existing patient safety challenges. Based on incident reporting data from three large US academic medical centers from January 2020 through December 2021, researchers found that patient safety event rates did not increase during the COVID-19 pandemic, but they did observe a relationship between staffing levels during the pandemic and patient safety event rates.
Goekcimen K, Schwendimann R, Pfeiffer Y, et al. J Patient Saf. 2023;19:e1-e8.
Incident reporting systems are common tools to detect patient safety hazards. This systematic review synthesized evidence from 41 studies using incident reporting system data to identify and characterize critical incidents. Medication-related incidents and incidents due to “active failures” were the most commonly reported events. The authors observe that only one in three studies reported on corrective actions due to the incidents, highlighting the need to emphasize the importance of learning from errors.
Sutton E, Booth L, Ibrahim M, et al. Qual Health Res. 2022;32:2078-2089.
Patient engagement and encouragement to speak up about their care can promote patient safety. This qualitative study explored patients’ psychosocial experiences after surviving abdominal surgery complications. Findings highlight an overarching theme of vulnerability and how power imbalances between patients and healthcare professionals can influence speaking up behaviors.
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.

Collaborative for Accountability and Improvement.  January 26, 2023, 2:00-3:00 PM (eastern).

Root cause analysis (RCA) is a recognized approach to examining failures by identifying causal factors to define improvement effort. This session will discuss challenges to the effective use of RCA results and examine an approach to present them that supports effective improvement action.
Portland, OR: Oregon Patient Safety Commission.
This site provides data and analysis from two Oregon Patient Safety Commission patient safety initiatives: the Patient Safety Reporting Program (PSRP) and Early Discussion and Resolution (EDR) effort. The review of 2021 PSRP data discusses the impact of the state adverse event reporting program and upcoming initiative to examine how organizational safety effort prioritization affects care in Oregon. The 2022 EDR analysis discusses the uptake of the program to generate conversations with patients and providers after a patient safety incident occurred.
Dynan L, Smith RB. Health Serv Res. 2022;57:1235-1246.
Nurses play a critical role in ensuring patient safety, and prior research has shown that better nurse-staffing ratios and nurse engagement can improve mortality rates. This study of nearly 300 Florida acute-care hospitals evaluated the effect of expenditures on continuing nurse education staffing ratios of several AHRQ Patient Safety Indicators (PSI). Increased spending on both improved outcomes in catheter-related blood stream infections, pressure ulcers, and deep vein thrombosis.
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).

HR 9377, 117th Cong, 2d Sess (2022).

The need for a national government-led patient safety effort has long been advocated for. This legislation outlines the structure of a federal agency to provide support for patient safety data collection, national incident analysis, and recommendation development.
Pedrosa Carrasco AJ, Bezmenov A, Sibelius U, et al. Am J Hosp Palliat Care. 2022:104990912211400.
Patients with medical complexities who are receiving palliative care may be at increased risk for patient safety events. This cross-sectional survey found that patient safety concerns were common among patients receiving specialist community palliative care in Germany. Patients reported that physical disability, physical and psychological symptoms, and side effects or complications from medication therapy were the most common causes of impaired safety, as well as the COVID-19 pandemic.
Perspective on Safety December 14, 2022

Ellen Deutsch, MD, MS, FACS, FAAP, FSSH, CPPS is a Medical Officer in the Center for Quality Improvement and Patient Safety at the Agency for Healthcare Research and Quality. Dr. Deutsch is a pediatric otolaryngologist and has vast experience in simulation and resilience engineering. We spoke with her about resilient healthcare and how resilient engineering principles are applied to improve patient safety.

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.