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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 2227 Results
Choi JJ, Rosen MA, Shapiro MF, et al. Diagnosis (Berl). 2023;Epub Aug 11.
Teamwork is increasingly seen as an important component of diagnostic excellence. Through a systematic review and observations of team dynamics in a hospital medical ward, researchers identified three areas requiring additional research- (1) team structure, (2) contextual factors, and (3) emergent states (e.g., shared mental models).
Brown CE, Snyder CR, Marshall AR, et al. J Gen Intern Med. 2023;Epub Aug 24.
Structural racism continues to perpetuate health disparities. As part of their study on how black patients with serious illness experience racism from providers, researchers conducted interviews with 21 providers to understand ways they address anti-Black racism in their practice. Providers felt unprepared to address racism with their patients, wanted to provide tools for patients to bring up their experiences while also acknowledging the additional burden this would place on Black patients, and thought patient- and provider-facing programs could facilitate discussions. Additionally, despite extensive research on the negative impacts of structural racism on health, participants cited the need for more data.
Ryan SL, Logan M, Liu X, et al. Jt Comm J Qual Patient Saf. 2023;Epub Jul 31.
I-PASS is a structured tool to improve handoffs and communication between clinicians and promote patient safety. This study examined I-PASS implementation practices over a six-year period in 10 departments at one large academic medical center. Researchers found that most clinical services successfully implemented I-PASS and those using I-PASS conducted the most efficient handovers.
Stærk M, Lauridsen KG, Johnsen J, et al. Resusc Plus. 2023;14:100410.
In situ simulation is a valuable tool to identify latent safety threats. In this study, 36 unannounced in situ in-hospital cardiac arrest (IHCA) simulations were conducted across 4 hospitals and identified 30 system errors. Errors were categorized as involving human, organization, hardware, or software errors. These system errors contributed to treatment delays and care omissions.

Grubenhoff JA, Cifra CL, Marshall T, et al. Rockville, MD: Agency for Healthcare Research and Quality; September 2023. AHRQ Publication No. 23-0040-5-EF.

Unique challenges accompany efforts to study and reduce diagnostic error in children. This issue brief discusses addressing obstacles associated with testing and care access limitations that affect diagnosis across a variety of pediatric care environments. It also provides recommendations for building capacity to advance pediatric diagnostic safety. This issue brief is part of a series on diagnostic safety.
McCarthy SE, Hogan C, Jenkins L, et al. BMJ Open Qual. 2023;12:e002270.
Debriefing after significant clinical events helps affected staff develop a shared mental model of what happened, why it happened, and how it can be prevented in the future. This paper describes development of training videos on after action reviews (AAR)s, a type of debriefing. The videos introduce AAR, show a simulated AAR debriefing, offer techniques for handing challenging situations within an AAR, and reflections on the benefits. The videos are available with the online version of the paper.

AHA Training. October 3-24, 2023. Tuesdays 2:00 PM - 3:30 PM (eastern).

Revisiting concept foundations is an important strategy to learn from experience and energize project participants. This virtual series will prepare participants to begin the implementation of the TeamSTEPPS program at their institutions and draw from the knowledge of others to make adjustments as needed to support teamwork training efforts.
Prior A, Vestergaard CH, Vedsted P, et al. BMC Med. 2023;21:305.
System weaknesses (e.g., resource availability, deficiencies in care coordination) threaten patient safety. This population-based cohort study including 4.7 million Danish adults who interacted with primary or hospital care in 2018, found that indicators of care fragmentation (e.g., higher numbers of involved clinicians, more transitions between providers) increased with patient morbidity level. The researchers found that higher levels of care fragmentation were associated with adverse outcomes, including potentially inappropriate prescribing and mortality.
Hooftman J, Dijkstra AC, Suurmeijer I, et al. BMJ Qual Saf. 2023;Epub Aug 9.
Diagnostic errors are common and have many contributing factors. This study analyzed more than 100 serious adverse event (SAE) reports in acute care using four investigation methods (e.g., Diagnostic Error Evaluation Research (DEER) taxonomy, Safer Dx Instrument) to identify common contributing factors. Transitions of care were particularly vulnerable to SAE, often due to incomplete communication between departments. Diagnostic errors occurred most often in the testing, assessment, and follow-up phases, with human factors as the most common contributing factor. Using multiple investigative methods supports more targeted interventions in each phase of diagnosis.
Williams SR, Sebok-Syer SS, Caretta-Weyer H, et al. BMC Med Educ. 2023;23:434.
Standardizing handoff training in residency programs can lead to safer, more effective handoffs. Researchers surveyed a sample of 687 residents and fellows from over 30 specialties about handoff training perspectives. Participants reported wide variability in handoff content and identified important aspects of handoff training (critical handoff elements, the impact of systems-level factors, impact of the handoff on providers and patients, professional duty, and addressing blame or guilt related to poor handoff experiences).
Armstrong Institute for Patient Safety and Quality. October 3 and 5, 2023.
Team training programs seek to improve communication and coordination among team members to reduce the potential for medical error. This virtual workshop will train participants to design, implement, and evaluate team training programs in their organizations based on the TeamSTEPPS model. 
Hibbert PD, Molloy CJ, Schultz TJ, et al. Int J Qual Health Care. 2023;35:mzad056.
Accurate and reliable detection and measurement of adverse events remains challenging. This systematic review examined the difference in adverse events detected using the Global Trigger Tool compared to those detected via incident reporting systems. In 12 of the 14 included studies, less than 10% of adverse events detected using the Global Trigger Tool were also found in corresponding incident reporting systems. The authors of the review emphasize the importance of using multiple approaches and sources of patient safety data to enhance adverse event detection.
Guppy JH, Widlund H, Munro R, et al. BMJ Lead. 2023;Epub Jul 7.
Incivility hinders clinical performance, increases errors, and negatively impacts safety culture. This review examines recent literature on the effects of incivility in healthcare and strategies to address it. The article proposes ways to implement those strategies, with an emphasis on the UK National Health Service. The authors conclude that tackling incivility begins with highlighting the issue organizationally, regionally, and nationally; ensuring robust reporting and recognition strategies; and, devising mechanisms to confront incivility.
Hilario C, Louie-Poon S, Taylor M, et al. Int J Soc Determinants Health Health Serv. 2023;53:343-353.
Structural racism is increasingly recognized as a social determinant of health. This systematic review identified 13 articles on the impact of racism on racialized adolescents. Most articles focused on the impact of racism on healthcare access and utilization, and in general or mental health care. Research into multiple forms of racism (i.e., institutional, interpersonal, internalized) and development and incorporation of robust measures of racism is needed to advance the field.
Falcone ML, Tokac U, Fish AF, et al. J Patient Saf. 2023;19:323-330.
AHRQ's Hospital Survey on Patient Safety Culture (SOPS) is widely used to measure hospital staff's opinion on safety culture in their organization. Exploratory factor analysis was conducted with SOPS data to compare with the six components of Patient Safety Culture Theoretical Framework. Construct validity was good, but the authors recommend creating a supplemental survey on deference to expertise and resilience.
Doshi S, Shin S, Lapointe-Shaw L, et al. JAMA Intern Med. 2023;183:924-932.
Missed recognition of early signs of clinical deterioration can result in transfer to the intensive care unit (ICU) or death. This study investigated whether critical illness events (transfer to ICU or death) impacted another patient's critical illness event in the subsequent six-hour period. Results suggest one or more critical illness events increase the odds of additional patient transfers into the ICU, but not of death. The authors present several explanations for this phenomenon.
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 October 17-18, 2023.
Mahomedradja RF, Schinkel M, Sigaloff KCE, et al. Br J Clin Pharmacol. 2023;89:1724-1735.
Despite extensive research and interventions, medication prescribing errors in hospital continue to occur. This review sought to identify prescribing errors and factors that facilitate or prevent prescribing errors. Prescribing errors were categorized as prescriber-, prescription-, technology-, or organization-related, or unclassified. Most errors were organization-related. The authors recommend examining facilitators and barriers to prescribing safety prior to implementing new interventions.

Infect Control Hosp Epidemiol. 2022-2023.

Health care–associated infections (HAIs) affect patients both during and after hospitalization. The use of patient safety methods as well as traditional infection control practices has resulted in significant successes in curbing HAIs such as central-line bloodstream infections. This set of practice guidelines will be developed and disseminated over the course of 2022-2023 to summarize preemptive actions and implementation strategies for prevention of HAIs.
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 latest PSRP report discusses the Commission's collaborative efforts in 2022 to implement changes aligned with the Safer Together report. The 2022 EDR analysis discusses the uptake of the program to generate conversations with patients and providers after a patient safety incident occurred.