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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 112 Results
Lucas SR, Pollak E, Makowski C. J Healthc Risk Manag. 2022;Epub Dec 4.
Medical errors that receive widespread media attention frequently spur health systems to reexamine their own culture and practices to prevent similar errors. This commentary describes one health system’s effort to identify and improve the system factors (systems, processes, technology) involved in the error. The action plan proposed by this project includes ensuring a just culture so staff feel empowered to report errors and near-misses; regularly review and improve medication delivery systems; build resilient medication delivery systems; and, establish methods of investigations.
Pado K, Fraus K, Mulhem E, et al. J Clin Psychol Med Settings. 2022;Epub Dec 12.
Medical errors may lead to feelings of distress for clinicians, but these errors can also be an opportunity for growth. This study used the Second Victim Experience and Support Tool (SVEST) and the Posttraumatic Growth Inventory to assess the extent, if any, of growth following a medical mishap. Rumination and the impact of the medical mishap were associated with distress among both physicians and nurses. The impact of the event was associated with growth in nurses, but no factor was associated with growth in physicians.
Institute for Safe Medication Practices. February 1-2, 2023.
This virtual workshop will explore tactics to ensure medication safety, including strategic planning, risk assessment, and Just Culture principles.
McCain N, Ferguson T, Barry Hultquist T, et al. J Nurs Care Qual. 2023;38:26-32.
Daily huddles can improve team communication and awareness of safety incidents. This single-site study found that implementation of daily interdisciplinary huddles increased reporting of near-miss events and improved team satisfaction and perceived team communication, collaboration, and psychological safety.

Cooper J, Thomas BJ, Rebello E, et al for the APSF Criminalization of Error Task Force. APSF Newsletter. October 2022; 37(3):80-81

Criminalizing human error can deter the transparency necessary to learn from incidents and improve health care. This position statement articulates the importance of avoiding the criminal prosecution to mistakes to instead focus on system failures to prevent conditions that permit errors to harm patients.
Singh H, Mushtaq U, Marinez A, et al. Jt Comm J Qual Patient Saf. 2022;48:581-590.
Diagnostic error continues to be a significant safety problem. Using a multimethod approach, this study developed a checklist of ten high-priority practices for diagnostic excellence which healthcare organizations can implement to address diagnostic errors. Priority practices include promoting speaking up behaviors through a just culture and psychologically safe environment; patient and family engagement in identifying, understanding, and addressing diagnostic safety concerns; and using multidisciplinary perspectives (including human factors and informatics) to understand factors contributing to diagnostic safety events.
Neiswender K, Figueroa-Altmann A, Granahan K, et al. Patient Safety. 2022;4:34-38.
Shifting to a nonpunitive approach to adverse events can improve error reporting and the overall safety culture. This article describes findings from focus groups with nurses at Children’s Hospital of Philadelphia (CHOP) regarding the perceived punitive nature of the hospital’s incident reporting system and outlines how those findings informed changes to the error review process. Lessons learned highlight the importance of who performs error follow-up, skills for navigating difficult conversations, transparency, and executive-level support. Five years after these program changes were implemented, 96% of nurses surveyed felt that the new process was nonpunitive.

Davies JM, Steinke C, Flemons WW. New York, NY: Productivity Press; 2022. ISBN: 9781032028132.

Look-alike packaging can contribute to patient harm. This book examines how a mix up involving potassium chloride resulted in the deaths of two patients. The Canadian organization involved applied Reason’s strategies to work past blame to examine the events and consider how just culture can be entrenched organization-wide to improve safety for patients, families, and those who care for them.
van Baarle E, Hartman L, Rooijakkers S, et al. BMC Health Serv Res. 2022;22:1035.
A just culture in healthcare balances organizational and individual responsibility and accountability when medical errors occur. This qualitative study including five healthcare organizations in the Netherlands concluded that open communication and emotional responses are important components of just culture. Researchers also identified several challenges in fostering a just culture, including how individual accountability is addressed and how to combine transparency with patient and clinician privacy.
van Marum S, Verhoeven D, de Rooy D. J Patient Saf. 2022;18:e1067-e1075.
Underutilization of error reporting systems may be due to a variety of factors, including a culture of fear or blame. This systematic review identified three types of factors influencing trust in error reporting – organizational factors (e.g., management style, focus on safety instead of punitive measures, leadership walk-rounds, established incident reporting systems), team factors (e.g., clearly defined team roles, relationships among teammates), and experience (e.g., knowledge of incident reporting systems, minimizing fear of shame or blame).
Weenink J-W, Wallenburg I, Hartman L, et al. BMJ Open. 2022;12:e061321.
There is a long-standing tension between health care regulation and just culture principles. This qualitative study explored the experiences of mental health professionals, managers and other healthcare organization staff, as well as inspectors, regarding the role of healthcare inspectors in enabling a just culture. Three themes emerged – (1) the role of the inspector as both a catalyst for learning and a potential barrier, (2) just culture involves relationships between different layers within and outside the organization, and (3) to enable just culture in which inspectors would strike a balance between organizational responsibility and timely regulatory intervention.

Institute for Safe Medication Practices.

A Just Culture supports effective reporting and learning from mistakes. This scholarship, inspired by the work and leadership of Judy Smetzer, former editor of the ISMP Medication Safety Alert! newsletter, will support three team or individual certifications in Just Culture practice. The application process is now closed.

Institute for Safe Medication Practices and the Just Culture Company. May 6, 2022.

Organizational factors can contribute to the occurrence of patient safety events and how health systems respond to such events. This webinar highlighted lessons learned in the aftermath of a fatal medication error, and strategies to improve patient safety at the organizational level through system design and accountability.
Wailling J, Kooijman A, Hughes J, et al. Health Expect. 2022;25:1192-1199.
Harm resulting from patient safety incidents can be compounded if investigating responses ignore the human relationships involved. This article describes how compounded harm arises, and it recommends the use of a restorative practices. A restorative approach focuses on (1) who has been hurt and their needs, and who is responsible for addressing those needs, (2) how harms and relationships can be repaired, and avenues to prevent the incident from reoccurring.
Wojcieszak D. J Patient Saf Risk Manag. 2022;27:15-20.
Open disclosure and apology for errors is recommended in healthcare. In this study, 38 state medical boards responded to a survey regarding disclosure and apology practices after medical errors. Findings suggest that state medical boards have generally favorable views toward clinicians who disclose errors and apologize, and that these actions would not make the clinician a target for disciplinary action; respondents had less favorable views towards legislative initiatives regarding apologies and disclosure.
Tee QX, Nambiar M, Stuckey S. J Med Imaging Radiat Oncol. 2022;66:202-207.
Diagnostic errors in radiology can result in treatment delays and contribute to patient harm. This article provides an overview of the common cognitive biases encountered in diagnostic radiology that can contribute to diagnostic error, and strategies to avoid these biases, such as the use of a cognitive bias mitigation strategy checklist, peer feedback, promoting a just culture, and technology approaches including artificial intelligence (AI).

Loller T. Associated PressMarch 30, 2022.

Reporting medical errors, learning from them, and improving systems is a cornerstone of improving patient safety. A just culture centers on moving from blaming individuals for medical errors towards a systems-based approach to learning what went on, in order to prevent similar errors in the future. The recent conviction of a nurse involved in the death of a patient has raised concerns that clinicians may not disclose medical errors out of fear of criminal prosecution and conviction.
Dawson R, Saulnier T, Campbell A, et al. Hosp Pediatr. 2022;12:407-417.
Voluntary error reporting remains underutilized in many clinical settings despite its importance for organizational learning and improved patient safety. This pediatric health system implemented a new safety event management system (SEMS) aimed at increased usability, de-centralized event follow-up, and closed-loop communication. The new SEMS resulted in more event reporting and less staff time spent on each report.