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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 2143 Results

Dwyer D, See P. ABC News. November 28, 2023.

Lack of respect for the concerns of patients and sensitivity to their situation detract from their safety and trust in the health care system. This story relates firsthand experience of maternal mistreatment of those harmed while receiving care.
Schlesinger M, Grob R. Hastings Cent Rep. 2023;53:s22-s32.
Involvement in patient safety incidents can erode patient trust in their own physicians and the healthcare system. This article summarizes the estimated frequency of lost trust after patient safety incidents, external factors contributing to mistrust, and approaches to restoring trust after incidents.
Atlanta, GA: Centers for Disease Control and Prevention; November 2023.
This annual analysis explores rates of health care-associated infections (HAIs) reported in the United States. Data from 2022 revealed decreases in central line–associated bloodstream infections and other hospital-acquired infections while reporting little progress in other healthcare settings. The current report includes data from the National Healthcare Safety Network (NHSN).

Dorset, UK:  Health Services Safety Investigations Body; October 2023.

Safety management systems (SMS) are employed in many high-risk industries, yet are not fully adopted in health care. This investigation report discusses the core safety elements of an SMS (policy, risk management, assurance, and promotion), how they are defined in a wide range of industries, and how they might be systemically embedded in the care environment to support safety culture, accountability, and maturity.

Washington DC; VA Office of the Inspector General; October 31, 2023; Report no. 22-03599-07.

Disclosure failures detract from learning, appropriate incident examination, and safe care delivery. This report examined factors contributing to poor disclosure practices associated with the care of three patients. Lack of report submission, uninitiated root cause analysis, and inadequate documentation were process weaknesses highlighted by the review. 
Olazo K, Gallagher TH, Sarkar U. J Patient Saf. 2023;19:547-552.
Marginalized patients are more likely to experience adverse events and it is important to encourage effective disclosure to reinforce and reestablish trust between patients and providers. This qualitative study involving clinicians and patient safety professionals explored challenges responding to and disclosing errors involving historically marginalized patients. Participants identified multilevel challenges, including fragmentation of care and patient mistrust as well a desire for disclosure training and culturally appropriate disclosure toolkits to support effective error disclosure.

Anaesth Intensive Care. 2023;51(6):372-421.

Centralized de-identified reports of patient safety events serve a core purpose for learning and improvement. This article collection contains research drawn from the Australian/New Zealand webAIRS database. Data reviewed include cesarean and pediatric regional anesthesia incidents submitted to webAIRS over a 13-year period.
Hald EJ, Gillespie A, Reader TW. J Contingencies Crisis Manage. 2023;31:752-766.
Including both patient/relative and staff perspectives in investigations provides a deeper understanding of the event. This study applies natural language processing methodology to 40 staff and 53 patient/relative witness statements into a C. difficile outbreak in a UK trust. This novel method revealed that staff identified a lack of training and understaffing, whereas patients/relatives identified communication failures and the physical environment as contributing factors.
Munn LT, Lynn MR, Knafl GJ, et al. J Res Nurs. 2023;28:354-364.
Nursing team dynamics can influence safety culture and willingness so speak up about errors and safety concerns. This survey of over 650 nurses and nurse managers underscored the importance of leader inclusiveness, safety climate, and psychological safety in cultivating speaking up behaviors among nursing team members.
Pozzobon LD, Rotter T, Sears K. Healthc Manage Forum. 2023;Epub Oct 13.
Patient and caregiver engagement in patient safety can improve individual outcomes and help identify safety threats. This article highlights the advantages of including patients in patient safety event reporting, including broadening the understanding of harm to include psychological and financial harms, identifying contributing factors to harm, and notes several organizational activities where patients and caregiver involvement can be integrated.

Rockville, MD: Agency for Healthcare Research and Quality; September 2023. AHRQ Publication no. 23-0082.

The sharing of data is a core element of a learning health system. AHRQ has released the Network of Patient Safety Databases (NPSD) Chartbook 2023, which offers an overview of nonidentifiable, aggregated patient safety event and near-miss information, voluntarily reported by AHRQ-listed Patient Safety Organizations across the country between June 2014 and December 2022. The chartbook outlines the extent of harm reported, distribution of patient safety events, near misses, and unsafe conditions. 
Nitsche E, Dreßler J, Henschler R. J Blood Med. 2023;14:435-443.
Transfusion errors can lead to serious patient harm. In this retrospective analysis of transfusion medical records and related documentation, researchers examined transfusion incident characteristics and logistical errors associated with incidents. Common logistical errors included elevated hemoglobin, inadequate bedside tests, inadequate patient identification, and laboratory errors.
Kavanagh KT, Cormier LE. Medicine (Baltimore). 2023;102:e35095.
Primary care plays an important role in identifying, avoiding and mitigating patient safety issues. This report highlights several patient safety priorities and how small (<10 providers) primary care practices can promote safe practice and outcomes for their patients.
Bagot KL, McInnes E, Mannion R, et al. BMC Health Serv Res. 2023;23:1012.
Unprofessional behavior can have a detrimental effect on coworkers, culture, and patient safety. This qualitative study presents perspectives of middle managers in hospitals that implemented a program allowing and encouraging workers to report unprofessional, as well as positive, behavior. Themes included staying silent but active (e.g., avoiding the unprofessional colleague), history and hierarchy, and double-edged swords (e.g., pros and cons of anonymous reporting).

Maxwell A. Washington DC: Office of Inspector General; September 2023. Report no. OEI-05-22-00290.

Falls are a persistent threat to patient safety and effective reporting of this adverse event can assist in understanding important gaps in care. This report examines the incidence of Medicare home health patients experiencing falls with major injury resulting in hospitalization that were not reported as required. 55% of falls were not documented thusly negatively impacting the viability of Care Compare as a reliable public resource for this information.
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.

United States Office of the Inspector General: 2010-2023.

Large-scale data analysis provides insights to generate evidence-based improvement action. This collection of reports provides access to investigations of the impact of healthcare-related harm events in Department of Health and Human Services (HHS) programs and across the United States health system. This set of publications not only examines weaknesses but provides recommendations for improvement on topics such as gaps in fall reporting by home health agencies, Medicare adverse events and the viability of payment incentives as a strategy for medical harm reduction.

Rockville, MD: Agency for Healthcare Research and Quality: November 2023.

Patient safety progress is dynamic, consistently producing evidence for application to generate improvements. This report is the fourth in a series funded by the Agency for Healthcare Research and Quality to track a prioritized set of emerging and existing safety approaches to confirm their value and effectiveness. This report will be compiled as new conclusions are formulated. Each review will be posted to the collection as they are completed. The first three Making Healthcare Safer reports, published in 2001, 2013, and 2020, have each served as a consolidated evidence source for clinicians, health system leadership, researchers, and government agencies. Chapter protocols and the results of an examination on patient and family engagement and report cards as a surgical improvement mechanism are now available. 
Leapfrog Group
Drawing from data reported by the Leapfrog Hospital Survey, the Agency for Healthcare Research and Quality (AHRQ), the Centers for Disease Control and Prevention (CDC), and the Centers for Medicare and Medicaid Services (CMS), this website provides grades for hospitals in the United States based on their safety. The Fall 2023 hospital safety grade results, documenting a reduction in both patient satisfaction scores and healthcare associated infection rates to pre-pandemic levels, are available. 

Rickert J, Järvinen TLN, 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 inherent in clinician strike actions. Older materials are available online for free.