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)

Displaying 1 - 20 of 206 Results

Registered nurses' efforts to ensure safety for home-dwelling older patients.

Save to Library

Lindberg C, Fock J, Nilsen P, et al. Scand J Caring Sci. 2022.

Providing in-home care for home-dwelling adults presents unique patient safety challenges. This qualitative study with 13 registered nurses in Sweden explored how nurses ensure safe home health care among home-dwelling older patients. Findings highlight the importance of continuity of care, trust between patients, caregivers, and nurses, and adapting safety requirements to meet environmental conditions and maintain a sense of home.

Explaining the negative effects of patient participation in patient safety: an exploratory qualitative study in an academic tertiary healthcare centre in the Netherlands.

Save to Library

Van der Voorden M, Ahaus K, Franx A. BMJ Open. 2023;13:e063175.

Patient engagement in healthcare is widely encouraged, but findings from some studies suggest that patient participation can have negative effects. This qualitative study with 16 patients and obstetric healthcare professionals examined the negative effects of patient participation in healthcare. Researchers identified four types of negative consequences from patient participation in safety – decreases in patient confidence, eroding of the patient-professional relationship, unwanted increases in patient responsibility, and excess time spent by professionals on the patient.

Accuracy in patient understanding of common medical phrases.

Save to Library

Gotlieb R, Praska C, Hendrickson MA, et al. JAMA Netw Open. 2022;5:e2242972.

Ensuring patients understand their diagnosis and care plan is important to achieving optimal outcomes. However, patients routinely report not understanding what their provider has told them. In this study, adults were asked for their understanding of jargon clinicians regularly use (“negative” test results, NPO) and a corresponding statement without jargon (“you do not have an infection”, “nothing by mouth”). Some jargon was better understood (“negative”) than other jargon (“occult infection”). Participant demographics were not significantly associated with understanding jargon.

Using consumer engagement strategies to improve healthcare safety for young people: an exploration of the relevance and suitability of current approaches.

Save to Library

Newman B, Joseph K, McDonald FEJ, et al. Health Expect. 2022;25:3215-3224.

Patient engagement focuses on involving patients in detecting adverse events, empowering patients to speak up, and emphasizing the patient’s role in a culture of safety. Young people ages 16-25 with experiences in cancer care, and staff who support young people with cancer were asked about their experiences with three types of patient engagement strategies. Four themes for engaging young people emerged, including empowerment, transparency, participatory culture, and flexibility. Across all these was a fifth theme of transition from youth to adult care.

Her child was stillborn at 39 weeks. She blames a system that doesn’t always listen to mothers.

Save to Library

Eldeib D. ProPublica. November 13, 2022.

Pregnancy is recognized as a high-risk condition for both mother and infant. This news story examines the potential for stillbirth and its preventability. Lack of respect for the concerns of mothers, inadequate attention to research, and poor patient education are discussed as contributors to stillbirth.

Social risk, health inequity, and patient safety.

Save to Library

Boisvert S. J Healthc Risk Manag. 2022;42:18-25.

Social determinants of health (SDOH) are non-medical factors that impact a person’s health and well-being. This commentary presents ways that risk managers can improve equity and patient safety by addressing two SDOH: health literacy and discrimination. The author recommends using existing risk management tools (e.g., error reporting, data collection) to develop strategies to address the negative impacts of SDOH.

Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan.

Save to Library

WebM&M Case September 28, 2022

This case describes a 20-year-old woman was diagnosed with a pulmonary embolism and occlusive thrombus in the right brachial vein surrounding a peripherally inserted central catheter (PICC) line (type, gauge, and length of time the PICC had been in place were not noted). The patient was discharged home but was not given any supplies for cleaning the PICC line, education regarding the signs of PICC line infection, or referral to home health services.

Patients' willingness and ability to identify and respond to errors in their personal health records: mixed methods analysis of cross-sectional survey data.

Save to Library

Lear R, Freise L, Kybert M, et al. J Med Internet Res. 2022;24:e37226.

As patients increasingly access their electronic health records, they often identify errors requiring correction. This survey of 445 patients in the United Kingdom found that the majority of patients are willing and able to identify and respond to errors in their electronic health records, but information-related and systems-related barriers (e.g., limited understanding of medical terminology, poor information display) disproportionately impact patients with lower digital health literacy or language barriers.

Family safety reporting in hospitalized children with medical complexity.

Save to Library

Mercer AN, Mauskar S, Baird JD, et al. Pediatrics. 2022;150:e2021055098.

Children with serious medical conditions are vulnerable to medical errors. This prospective study examined safety reporting behaviors among parents of children with medical complexity and hospital staff caring for these patients in one tertiary children’s hospital. Findings indicate that parents frequently identify medical errors or quality issues, despite not being routinely advised on how to report safety concerns.

Association of patient and family reports of hospital safety climate with language proficiency in the US.

Save to Library

Khan A, Parente V, Baird JD, et al. JAMA Pediatr. 2022;176:776-786.

Parent or caregiver limited English proficiency (LPE) has been associated with increased risk of their children experiencing adverse events. In this study, limited English proficiency was associated with lower odds of speaking up or asking questions when something does not appear right with their child’s care. Recommendations for improving communication with limited English proficiency patients and families are presented.

Analysis of readmissions in a mobile integrated health transitional care program using root cause analysis and common cause analysis.

Save to Library

Buitrago I, Seidl KL, Gingold DB, et al. J Healthc Qual. 2022;44:169-177.

Reducing hospital 30-day readmissions is seen as a way to improve safety and reduce costs. Baltimore City mobile integrated health and community paramedicine (MIH-CP) was designed to improve transitional care from hospital to home. After one year in operation, MIH-CP performed a chart review to determine causes of readmission among patients in the program. Root cause analysis indicated that at least one social determinant of health (e.g., health literacy) played a role in preventable readmissions; the program was modified to improve transitional care.

A Case of Mistaken Capacity: Why A Thorough Psychosocial History Can Improve Care.

Save to Library

WebM&M Case March 31, 2022

This Spotlight Case describes an older man incidentally diagnosed with prostate cancer, with metastases to the bone. He was seen in clinic one month after that discharge, without family present, and scheduled for outpatient biopsy. He showed up to the biopsy without adequate preparation and so it was rescheduled. He did not show up to the following four oncology appointments.

Diagnostic error experiences of patients and families with limited English-language health literacy or disadvantaged socioeconomic position in a cross-sectional US population-based survey.

Save to Library

Bell SK, Dong J, Ngo L, et al. BMJ Qual Saf. 2022;Epub Feb 4.

Limited English-language health literacy (LEHL) and disadvantaged socioeconomic position (dSEP) have been shown to increase risk of adverse events and near misses. Using data from the 2017 Institute for Healthcare Improvement-National Patient Safety Foundation study, researchers found, while respondents with LEHL or dSEP experienced diagnostic errors at the same rate as their counterparts, they were more likely to report unique contributing factors and more long-term emotional, physical, and financial harm.

Disparities after discharge: the association of limited English proficiency and postdischarge patient-reported issues.

Save to Library

Malevanchik L, Wheeler M, Gagliardi K, et al. Jt Comm J Qual Patient Saf. 2021;47:775-782.

Communication in healthcare is essential but can be complicated, particularly when there are language barriers between providers and patients. This study evaluated a hospital-wide care transitions program, with a goal of universal contact with discharged patients to identify and address care transition problems. Researchers found that the program reached most patients regardless of English proficiency, but that patients with limited English proficiency experienced more post-discharge issues, such as difficulty understanding discharge instructions, medication concerns and follow-up questions, and new or worsening symptoms.

Culture Clash No More: Integration and Coordination of Disease Treatment and Palliative Care

Save to Library

WebM&M Case November 30, 2021

A 77-year-old man was diagnosed with a rectal mass. After discussing goals of care with an oncologist, he declined surgical intervention and underwent targeted radiotherapy before being lost to follow up. The patient subsequently presented to Emergency Department after a fall at home and was found to have new metastatic lesions in both lungs and numerous enhancing lesions in the brain. Further discussions of the goals of care revealed that the patient desired to focus on comfort and on maintaining independence for as long as possible. The inpatient hospice team discussed the potential role

Associations of person-related, environment-related and communication-related factors on medication errors in public and private hospitals: a retrospective clinical audit.

Save to Library

Manias E, Street M, Lowe G, et al. BMC Health Serv Res. 2021;21:1025.

This study explored associations between person-related (e.g., individual responsible for medication error), environment-related (e.g., transitions of care), and communication-related (e.g., misreading of medication order) medication errors in two Australian hospitals. The authors recommend that improved communication regarding medications with patients and families could reduce medication errors associated with possible or probable harm.

Health literacy-related safety events: a qualitative study of health literacy failures in patient safety events.

Save to Library

Morrison AK, Gibson C, Higgins C, et al. Pediatr Qual Saf. 2021;6:e425.

Limited health literacy can lead to patients or caregivers misunderstanding care instructions. Researchers examined safety events occurring at one children’s hospital over a nine-month period and found that health literacy-related events accounted for 4% of all safety events. Health literacy-related events generally involved problems with medication (e.g., unclear discharge medication instructions, conflicting instructions), system processes (e.g.., failures to address language barriers), and discharge and transitions (e.g., unclear equipment information, unclear instructions about upcoming tests).

Unite for Safe Care.

Save to Library

Patient Safety Movement. September 17, 2021.

Patient safety is a global challenge for the health care community. This webinar coincided with World Patient Safety Day and presented two tracks for both the profession and the public that highlighted issues impacting maternal care safety and high reliability. Those who have lost their lives to medical error were also honored during the event. The session speakers included Tedros Adhanom Ghebreyesus, PhD, MSc, Jeff Brady, MD, and Albert Wu, MD.

Assessment of patient-preferred language to achieve goal-aligned deprescribing in older adults.

Save to Library

Green AR, Aschmann H, Boyd CM, et al. JAMA Netw Open. 2021;4:e212633.

Effective communication between patient and provider is key to successful deprescribing. Participants in this study were asked to rate potential phrases a clinician may use to explain why stopping or reducing a medication is important. The most preferred phrase involved an explanation of risk of side effects associated with the medications while the least preferred options focused on the effort involved in taking the medication and “this medication is unlikely to help you function better”. Understanding the patient’s priorities can help frame the conversation around deprescribing.

How medical jargon can make COVID health disparities even worse.

Save to Library

Kritz F. Shots. National Public Radio; May 24, 2021.

Health literacy efforts address challenges related to both language and effective communication tactics. This story discussed how lack of language and information clarity reduced patient education effectiveness during the pandemic and highlights several efforts to address them including information product translation services.

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