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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 38 Results
Lacson R, Khorasani R, Fiumara K, et al. J Patient Saf. 2022;18:e522-e527.
Root cause analysis is a commonly used tool to identify systems-related factors that contributed to an adverse event. This study assessed a system-based approach, (i.e., collaborative case reviews (CCR) co-led by radiology and an institutional patient safety program) to identify contributing factors and explore the strength of recommended actions in the radiology department at a large academic medical center. Stronger action items, such as standardization of processes, were implemented in 41% of events, and radiology had higher completion rates than other hospital departments.
Farag A, Vogelsmeier A, Knox K, et al. J Gerontol Nurs. 2020;46.
Using a random sample of 500 nursing home nurses in one state, this study tested a proposed predictive model assessing nurses’ willingness to report medication near-misses. On a scale from 0 to 3 (where high scores indicate more willingness to report) the mean score of nurses’ willingness to report near-miss incidents was 1.79. The model predicted a 19% variance in willingness to report. The strongest predictors of willingness to report were non-punitive safety climate, transformational leadership, trusting relationships with nurse managers, and familiarity with the reporting system. The authors conclude that social and system factors are necessary to improve nurses’ voluntary reporting of medication near-misses.
O’Donovan R, McAuliffe E. Int J Qual Health Care. 2020;32:240-250.
This systematic review analyzed 36 articles exploring factors enabling psychological safety in healthcare teams. The review identified five themes of enabling factors: (1) priority for patient safety, such as safety culture or leadership behavior; (2) improvement or learning orientation leading to a culture of continuous improvement or change-oriented leadership; (3) support from peers, leadership or the organization; (4) familiarity between and across teams and with team leaders, and; (5) status, hierarchy and inclusivity. These themes can aid future objective measures of psychological safety and interventions to improve psychological safety within teams. 
Rockville, MD: Agency for Healthcare Research and Quality; March 2020. AHRQ Publication No. 20-0030.
Patient safety organizations (PSOs) collect and analyze protected incident data from across the United States. Expert analysis of PSO data can be utilized to inform design and implementation of local initiatives. This brochure provides guidance for health care organizations regarding benefits of working with a PSO and what to consider when choosing one.
Rockville, MD: Agency for Healthcare Research and Quality; August 2019.
The Comprehensive Unit-based Safety Program (CUSP), originally developed at Johns Hopkins Hospital by Dr. Peter Pronovost and colleagues, has been instrumental in driving patient safety improvement in several landmark patient safety initiatives. The CUSP approach emphasizes improving safety culture by through a continuous process of reporting and learning from errors, improving teamwork, and engaging staff at all levels in safety efforts.  Most recently, an AHRQ-funded project using the CUSP model achieved a 40% reduction of central line–associated bloodstream infections in intensive care units nationwide. This toolkit includes modules on how to build the CUSP team, identify recurring safety concerns, and improve teamwork and communication.
Fulop NJ, Ramsay AIG. BMJ. 2019;365:l1773.
Quality and safety improvement in health care is complex and requires insights and buy-in from various perspectives to achieve lasting progress. This commentary discusses the role of leadership, systemwide staff engagement, external influences, and processes that support prioritization and implementation of sustainable quality improvement strategies.
Agarwala A, McRichards K, Rao V, et al. Jt Comm J Qual Patient Saf. 2019;45:170-179.
Emergency manuals are employed in high-risk industries to guide teams during critical events. This commentary recommends a structured approach to emergency manual program implementation focused on preparation, design, action, and maintenance.

Kirby J, Cannon C, Darrah L, et al. Patient Exp J. 2018;5:76-90.

Parents are important advocates for the safe care of their children. This commentary describes how one hospital built a toolkit to operationalize family members as partners to improve safety. The organization applied high reliability concepts to identify, recognize, and support projects at the hospital to successfully use patients' perspectives to design improvements.
Rosen M, Mueller BU, Milstone AM, et al. Jt Comm J Qual Patient Saf. 2017;43:224-231.
This commentary describes the development of a multidisciplinary council to collectively lead patient safety efforts for children's hospitals in a large health system. The authors highlight the value the council brought to project coordination, standard setting, and performance improvement across the organization.
Watson SR, Pronovost PJ. J Patient Saf. 2016;12:165-6.
Substantial progress has been made in improving health care safety, but more work is needed to optimize those efforts. Advocating for the development of an infrastructure that supports safety improvement, this editorial suggests that performance measures, initiative coordination, and recognition of local successes are ways to advance patient safety.
Pronovost PJ, Demski R, Callender T, et al. Jt Comm J Qual Patient Saf. 2013;39:531-544.
This study updates the previously described progress of patient safety efforts at Johns Hopkins Hospital. In 2012, hospital leaders declared their goal of exceeding The Joint Commission Top Performer award thresholds by achieving at least 96% compliance on accountability measures. The program included creating a robust quality management infrastructure through the Armstrong Institute, engaging frontline clinicians in peer learning communities, and transparently reporting monthly data with a detailed step-based accountability plan for underachieving metrics. This study describes how the hospital was able to sustain performance on all of the accountability measures through 2014. The authors attribute their continued success to establishing an enduring quality management infrastructure, a project management office, and a formal accountability framework. This model highlights the degree of organization required to create lasting changes that improve patient safety across health systems.
Vaida AJ. J Med Toxicol. 2015;11:262-264.
Poison control centers serve as data collection points for ambulatory medication errors that result in harm. This commentary highlights how reporting programs that collect such data can collaborate and disseminate information about medication-related incidents to reduce errors and promote improvement.
Braddock CH, Szaflarski N, Forsey L, et al. J Gen Intern Med. 2015;30:425-33.
This before-and-after study examined the impact of a patient safety project which included simulation training, teamwork training, and patient safety educational conferences. The authors found a decrease in hospital-acquired complications, better nurse perceptions of safety culture, and an improved observed-to-expected mortality ratio. These promising preliminary results should spur larger studies of these organizational safety efforts.
Pettker CM, Thung SF, Lipkind HS, et al. Am J Obstet Gynecol. 2014;211:319-25.
A comprehensive obstetric patient safety program at an academic hospital—which involved teamwork training, standardizing care protocols, and establishing a robust quality assurance mechanism (including a dedicated patient safety nurse and an anonymous error reporting system)—has previously been shown to decrease adverse events and improve safety culture. This follow-up study demonstrates that the program was also associated with a reduction in malpractice claims and total payments over a 5-year period. The relationship between patient safety and malpractice claims is complex, as claims data likely do not correlate with overall safety. However, the results of this study, along with other studies showing that full disclosure of adverse events can reduce malpractice claims, lends support to the belief that improving safety culture can have downstream effects on malpractice lawsuits at the health-system level.
Lin DM, Weeks K, Holzmueller CG, et al. Jt Comm J Qual Patient Saf. 2016;39:51-60, AP3.
As a result of the landmark Keystone ICU project, central line–associated bloodstream infections (CLABSIs) have emerged as a flagship patient safety target in recent years. The national Comprehensive Unit-Based Safety Program (CUSP) initiative aims to further disseminate these results by creating state-level cohort collaboratives. This current report of the initiative's implementation and sustainability in Hawaii continues the project's encouraging results, with CLABSI rates significantly decreased across the entire state. Most notably, Hawaii has successfully spread this program beyond adult intensive care units (ICUs) into pediatric and neonatal ICUs, and even non-ICU wards. The article outlines specific innovative tools and strategies utilized by the Hawaii collaborative, with an emphasis on cultural change and establishing new local norms. An AHRQ-sponsored CUSP toolkit is freely available.
Health Research & Educational Trust, MHA Keystone Center.
This Web site provides resources for two comprehensive unit-based safety programs (CUSP) designed to reduce central line–associated bloodstream infections and catheter-associated urinary tract infections.
Sarkar B, Brunsvold ME, Cherry-Bukoweic JR, et al. J Trauma. 2011;71:1447-53; discussion 1453-4.
A multifaceted program designed to optimize care of trauma patients resulted in a sustained improvement in trauma mortality over a 5-year period in this single-institution study. Part of the intervention included successful efforts to reduce health care–associated infections.