Skip to main content

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

Search Tips
Save
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Search By Author(s)
Additional Filters
Approach to Improving Safety
Displaying 1 - 20 of 276 Results
Kirkup B, Titcombe J. BMJ. 2023;382:1972.
The latent nature of failure in health care is enabled by organizational inability or unwillingness to listen and respond to the concerns of patients, families, and clinicians. This commentary discusses a rare criminal event in the British National Health System (NHS) and the factors that allowed continued criminal activity to occur over time.

Peterson M. Los Angeles Times. September 5, 2023.

Safe practice in community pharmacy is challenged by production pressure, workforce shortages, and multitasking. This story examined the mistakes made at major retail pharmacy chains in California. It provides examples perpetrated across the industry to target universal areas of needed improvement and potential strategies to address them.
Wallin A, Ringdal M, Ahlberg K, et al. Scand J Caring Sci. 2023;37:414-423.
Numerous factors can hinder safe radiology practices, such as communication failures and image interpretation errors. Based on semi-structured interviews with 17 radiologists in Sweden, this study identified 20 themes at the individual-, organization-, technology-, task-and environment-levels describing factors supporting patient safety in radiology. Factors described by participants included the use of standardized tools and work routines (e.g., checklists), handoffs, and incident reporting systems.
Griffeth EM, Gajic O, Schueler N, et al. J Patient Saf. 2023;19:422-428.
Voluntary reporting is an important tool for institutions to identify latent safety threats before they reach the patient but barriers to reporting result in low reporting rates. This quality improvement (QI) project aimed to increase near miss and error reporting within 9 intensive care units (ICU) in one healthcare system. After identifying barriers to reporting (e.g., user difficulty with online reporting system), a multi-faceted intervention was developed and implemented. Error reporting increased in 6 of 9 ICUs following implementation, with a significant increase in near miss reports.
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.
Alfred MC, Wilson D, DeForest E, et al. Jt Comm J Qual Patient Saf. 2023;Epub Jun 15.
In the United States, women and birthing people of color experience disproportionately high rates of mortality and severe maternal morbidity (SMM). Researchers analyzed two years of incident reports (IR) to ascertain potential system issues contributing to SMM and racial/ethnic disparities at one hospital. Non-Hispanic Black individuals were over-represented in IRs, but there were no statistically significant differences in harm level.
Cho H, Steege LM, Arsenault Knudsen ÉN. Res Nurs Health. 2023;46:445-453.
Psychological safety, the feeling of confidence that speaking up will not result in punishment or shame, can have a positive impact on both patient and healthcare worker outcomes. Conducted in 2021, this study involved 867 hospital nurses in the United States. Nurses with higher psychological safety were more satisfied with their jobs, less likely to leave in the next year, and reported higher patient safety ratings.
Lainidi O, Jendeby MK, Montgomery A, et al. Front Psychiatry. 2023;14:111579.
Encouraging frontline healthcare workers to voice concerns is an important component of safety culture. This systematic review of 76 qualitative studies explored how speaking up behaviors and silence are measured in healthcare. The authors identified several evidence gaps, including a reliance on self-reported data and overrepresentation of certain demographic characteristics.
Øyri SF, Søreide K, Søreide E, et al. BMJ Open Qual. 2023;12:e002368.
Reporting and learning from adverse events are core components of patient safety. In this qualitative study involving 15 surgeons from four academic hospitals in Norway, researchers identified several individual and structural factors influencing serious adverse events as well as both positive and negative implications of transparency regarding adverse events. The authors highlight the importance of systemic learning and structural changes to foster psychological safety and create space for safe discussions after adverse events.
Caspi H, Perlman Y, Westreich S. Safety Sci. 2023;164:106147.
Near-misses or “good catches” are incidents that could have resulted in patient harm but did not due to it being caught at the last minute or through sheer luck. Reporting near-misses can help organizations learn and enact changes if necessary, but near-misses are not frequently reported. This study presents enablers and barriers to reporting near-misses.
Delpino R, Lees-Deutsch L, Solanki B. BMJ Open Qual. 2023;12:e002047.
Following the 2013 release of the Report of The Mid Staffordshire NHS Foundation Trust inquiry, National Health Service (NHS) Trusts have made substantial efforts to increase staffs’ willingness to speak up about patient safety concerns. One method is the creation of confidential resources who provide staff support: Freedom to Speak Up Guardians (FTSUG) and Confidential Contacts (CC). This study explored perspectives of FTSUG and CC on how they best support staff and how leaders can encourage speaking up behavior.
Armstrong AA. J Healthc Qual. 2023;45:125-132.
Healthcare-acquired pressure injuries (HAPI) can result in increased lengths of stay, hospital readmissions, and lower quality of life. This article describes the experience of one hospital which, after it discovered it had higher-than-average HAPI rates, conducted a root cause analysis to determine contributing factors and identify potential solutions. Dedicated nursing staff were hired and trained, and an electronic health record form was developed to document and track HAPI. A root cause analysis was completed for each HAPI to identify trends and implement improvements.
Wawersik DM, Boutin ER, Gore T, et al. J Healthc Leadersh. 2023;15:59-70.
Psychological safety promotes speaking up and error reporting in the workplace, and many system and individual characteristics interact to promote or hinder reporting behavior. This review highlights individual characteristics that encourage error reporting, (confidence and positive perception of self, the organization, and leadership) or create barriers (self-preservation associated with fear and negative perceptions of self, the organization, and leadership).
May 4, 2023
The implementation of effective patient safety initiatives is challenging due to the complexity of the health care environment. This curated library shares resources summarizing overarching ideas and strategies that can aid in successful program execution, establishment, and sustainability.
Perspective on Safety April 26, 2023

Throughout 2022, AHRQ PSNet has shared research that elucidates the complex nature of misdiagnosis and diagnostic safety. This Year in Review explores recent work in diagnostic safety and ways that greater safety may be promoted using tools developed to improve diagnostic practices.

Throughout 2022, AHRQ PSNet has shared research that elucidates the complex nature of misdiagnosis and diagnostic safety. This Year in Review explores recent work in diagnostic safety and ways that greater safety may be promoted using tools developed to improve diagnostic practices.

Mahmoud HA, Thavorn K, Mulpuru S, et al. BMJ Open Qual. 2023;12:e002134.
Incident reporting systems offer important opportunities for health systems to learn from safety events and improve outcomes. This systematic review of 22 studies identified barriers and facilitators influencing how health systems use and learn from incident reporting systems. Barriers included inadequate organizational support and resources, weak safety culture, lack of training and feedback, and a punitive environment. Factors supporting continuous improvement based on incident reporting systems included continuous training for staff, a just culture, leadership investment, and tangible improvements stemming from incident analysis.
Stone A, Jiang ST, Stahl MC, et al. JAMA Otolaryngol Head Neck Surg. 2023;149:424-429.
Identifying and classifying adverse events is an important, yet often challenging, component of incident reporting. This article describes the development and testing of a novel Quality Improvement Classification System (QICS) designed to incorporate adverse events in both inpatient and outpatient settings across medical and surgical specialties in order to capture a broader range of outcomes related to patient care, including organizational issues, near-miss events, and expected deviations from ideal outcomes of surgery.

Bean M, Carbajal E. Becker's Hospital Review. March 29, 2023.

The RaDonda Vaught conviction reverberated throughout health care and marked weaknesses in systems response to errors and the clinicians who make them. This news article examines how health care organizations renewed efforts to establish and nurture a culture of safety and error reporting in service of safe patient care and learning from mistakes.
Idilbi N, Dokhi M, Malka-Zeevi H, et al. J Nurs Care Qual. 2023;38:264-271.
If reported, near misses – also called “good catches” – present opportunities for healthcare organizations to learn about potential errors, identify system improvements, and improve safety culture. This mixed-methods study including 199 nurses, who worked in COVID-19 units, found that intent to report near misses was high (78%) but follow-through on reporting was low (20%). Qualitative analyses highlight the role that personnel/physical/mental overload, poor departmental organization, and fear of punitive measures play in underreporting near-miss events.
Perspective on Safety December 14, 2022

This collaborative piece with the Centers for Medicare & Medicaid Services discusses the current state of patient safety measurement, advancements in measuring patient safety, and explores future directions.

This collaborative piece with the Centers for Medicare & Medicaid Services discusses the current state of patient safety measurement, advancements in measuring patient safety, and explores future directions.

Michelle Schreiber photograph

We spoke to Dr. Michelle Schreiber about measuring patient safety, the CMS National Quality Strategy, and the future of measurement. Michelle Schreiber, MD, is the Deputy Director of the Center for Clinical Standards and Quality and the Director of the Quality Measurement and Value-Based Incentives Group at the Centers for Medicare & Medicaid Services.