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
Displaying 1 - 20 of 2331 Results

Agency for Healthcare Policy and Research: April 27, 2023.

Ambulatory surgery centers (ASC) experience a variety of error types that can be acerbated by poor safety culture. This webcast provided information on AHRQ’s Surveys on Patient Safety Culture™ (SOPS®) Ambulatory Surgery Center (ASC) Survey, including a review of the SOPS ASC program, survey administration, database submission, and available resources.
AHA Training. MetroHealth, Cleveland, OH, June 21-22, 2023.
This education program will present group-focused opportunities for participants to learn how to apply Agency for Healthcare Quality and Research TeamSTEPPS 2.0 curriculum methods to develop staff training and improve team communication in their organizations.

Institute for Healthcare Improvement. September 13 - November 7, 2023.

Root cause analysis (RCA) is a widely recognized retrospective strategy for learning from failure that is challenging to implement. This series of webinars will feature an innovative approach to RCA that expands on the concept to facilitate its use in incident investigations. Instructors for the series will include Dr. Terry Fairbanks and Dr. Tejal K. Gandhi.
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.

Patel J. PM Healthcare Journal. Spring 2023(4):5-18.

Language discordance is known to degrade medication safety. The article discusses an examination of English pharmacists’ reactions and responses to language barriers with patients. The results highlight the need for improved training and support for pharmacists to effectively dispense medications and counsel patients with whom they don’t share a common language.
Riblet NB, Soncrant C, Mills PD, et al. Mil Med. 2023;Epub Mar 31.
Patient suicide is a sentinel event, and suicide among veterans has gained attention. In this retrospective analysis of suicide-related events reported to the Veterans Health Administration (VHA) National Center for Patient Safety between January 2018 and June 2022, researchers found that deficiencies in mental health treatment, communication challenges, and unsafe environments were the most common contributors to suicide-related events.
Jeffries M, Salema N-E, Laing L, et al. BMJ Open. 2023;13:e068798.
Clinical decision support (CDS) systems were developed to support safe medication ordering, alerting prescribers to potential unsafe interactions such as drug-drug, drug-allergy, and dosing errors. This study uses a sociotechnical framework to understand the relationship between primary care prescribers’ safety work and CDS. Prescribers described the usefulness of CDS but also noted alert fatigue.
Hyvämäki P, Sneck S, Meriläinen M, et al. Int J Med Inform. 2023;174:105045.
Insufficient or incorrect transfer of patient information, whether caused by human or organizational factors, can result in adverse events during transitions of care. This study used four years of incident reports to identify the types, causes, and consequences of health information exchange- (HIE) related patient safety incidents in emergency care, (ED) emergency medical services (EMS), or home care. The two main kinds of HIE-related incidents were (1) inadequate documentation and inadequate use of information (e.g., deficiencies in content), and (2) causes related to the health professional or organization; consequences were adverse events or additional actions to prevent, avoid, and correct adverse events.
Folcarelli P, Hoffman J, Janes M, et al. J Healthc Risk Manag. 2023;Epub May 2.
Hospital mergers may improve some safety outcomes but also present challenges. This commentary describes how a third-party proactive risk assessment, ideally prior to the merger, can identify strengths and weaknesses of the organizations' safety cultures. The article describes an insurer-directed assessment, but other resources are also available, such as from the Institute for Healthcare Improvement National Action Plan.
Cohen TN, Berdahl CT, Coleman BL, et al. J Nurs Care Qual. 2023;Epub May 9.
Institutional error and near-miss reporting helps identify systemic weaknesses and areas for improvement. COVID-19 presented a unique environment to study error reporting during organizationally stressful times. In this study, incident reports of medication errors or near misses during a COVID-19 surge were analyzed. Skill-based (e.g., forgetting to administer a dose) and communication errors were the most common medication safety events.
Arnal-Velasco D, Heras-Hernando V. Curr Opin Anaesthesiol. 2023;36:376-381.
The Safety II framework and organizational resilience both focus on what goes right in healthcare and adjusting to disturbances through anticipation, monitoring, responding, and learning. This narrative review highlights recent research conducted within a Safety II and resilience framework such as Learning from Excellence and debriefing "what went right" after simulation training. The authors suggest learning from errors or what goes right should be reframed simply as learning.
Rainer T, Lim JK, He Y, et al. Hosp Pediatr. 2023;13:461-470.
Structural racism and implicit biases can affect clinical judgement and impede the delivery of effective mental health care. Based on a case of an adolescent Black girl navigating through the pediatric behavioral health system, this article discusses how structural racism and health disparities in behavioral health care contributed to misdiagnosis and poor care. The authors outline several actions at the structural, institutional, and interpersonal levels to address racism’s impact on pediatric mental and behavioral healthcare.

Lai B, Horn J, Wilkinson J, et al. Fam Pract Manag. 2023;30(2):13-17.

Morbidity and mortality (M&M) conferences are an established mechanism used to facilitate discussion of errors to generate learning. This peer-reviewed article discusses how one organization implemented an M&M program. The authors share steps taken to support success which include case selection, nonjudgmental culture, and subject matter expert involvement.
Moran JM, Bazan JG, Dawes SL, et al. Pract Radiat Oncol. 2023;13:203-216.
Safety risks are present in oncology radiation therapy. This recommendation builds on existing intensity modulated radiation therapy (IMRT) standards to highlight the importance of interdisciplinary engagement, training, and technology implementation to ensure high quality, safe IMRT is delivered to patients.
Yackel EE, Knowles RS, Jones CM, et al. J Patient Saf. 2023;Epub May 1.
The COVID-19 pandemic dramatically changed healthcare delivery and exacerbated threats to patient safety. Using Veterans Health Administration (VHA) National Center for Patient Safety data, this retrospective study characterized patient safety events related to COVID-19 occurring between March 2020 and February 2021. Delays in care and exposure to COVID-19 were the most common events and confusion over procedures, missed care, and failure to identify COVID-positive patients before exposures were the most common contributing factors.
Seeburger EF, Gonzales R, South EC, et al. JAMA Netw Open. 2023;6:e239057.
Verbal or physical violence towards healthcare workers can result in harm of both staff and patients. Based on semi-structured interviews with 25 registered nurses working in the emergency department (ED) at one large academic health system, the authors explored nursing perspectives on how EHR-based behavioral flags – used to identify incidents of workplace violence – can promote clinician safety. Participants identified benefits of the flags as well as concerns (e.g., introduction of bias, potential damage to the patient-clinician relationship), highlighted necessary system improvements, and how related challenges in the ED (e.g., unmet mental health needs of patients, COVID-19-related burnout) can contribute to workplace violence.
Royce CS, Morgan HK, Baecher-Lind L, et al. Am J Obstet Gynecol. 2023;228:369-381.
Racism and implicit biases can threaten the safety of care. The authors in this article outline how implicit bias can affect health professional trainees and impact patient care in obstetrics and gynecology, and outlines strategies to address implicit bias through bias awareness and management curricula, ensuring a supportive learning environment, and faculty development.

Powell M. J Health Org Manag. 2023;37(1):67-83.

Individual, team, and organizational willingness to identify and address safety problems is an important indicator of safety culture. The authors of this article apply ten perspectives on organizational silence to understand the organizational failures contributing to dangerous opioid prescribing practices at Gosport Hospital.
Allen G, Setzer J, Jones R, et al. Jt Comm J Qual Patient Saf. 2023;49:247-254.
Reconciling medication lists at transitions of care is a widely recognized safety strategy; however, other parts of the electronic health record (EHR) - allergies and problem lists - also need reconciliation. This article describes an academic medical system's quality improvement project to increase rates of complete reconciliation of problems, medications, and allergies in the EHR. Twenty-six cycles of Plan-Do-Study-Act increased completion rates from 20% to 80%.