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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 183 Results
Charles MA, Yackel EE, Mills PD, et al. J Patient Saf. 2022;18:686-691.
The first surge of the COVID-19 pandemic forced healthcare organizations to respond to patient safety issues in real-time. The Veterans Health Administration’s National Center for Patient Safety established two working groups to rapidly monitor quality and safety issues and make timely recommendations to staff. The formation, activities, and primary themes of safety issues are described.
Keller C. Health Aff (Millwood). 2022;41:1353-1356.
Communication failures due to hierarchy and silos create opportunities for adverse medication and treatment events. This narrative essay discusses gaps in care coordination that contributed to anticoagulant medication errors. The author outlines areas for improvement such as assignment of accountability for error and commitment to the learning health system as avenues for improvement.

London, England: NHS England; August 2022.

Effective response to medical error requires a comprehensive systemic and process-focused incident examination approach to ensure organizational learning. This framework will replace the current method used by the UK National Health Service (NHS) to support overarching patient safety strategic aims for the agency.
Giardina TD, Shahid U, Mushtaq U, et al. J Gen Intern Med. 2022;37:3965-3972.
Achieving diagnostic safety requires multidisciplinary approaches. Based on interviews with safety leaders across the United States, this article discusses how different organizations approach diagnostic safety. Respondents discuss barriers to implementing diagnostic safety activities as well as strategies to overcome barriers, highlighting the role of patient engagement and dedicated diagnostic safety champions.
Gilmartin HM, Hess E, Mueller C, et al. Health Serv Res. 2022;57:385-391.
Ideal clinical learning environments (CLE) support employee engagement, satisfaction, and a culture of safety. The Learning Environment and High Reliability Practices Survey (LEHR) was used to determine the association between ideal CLE and job satisfaction, burnout, intent to leave, and staff turnover. Learning environments with higher average LEHR scores were associated with higher employee engagement, retention, and safety climate scores.
Amalberti R, Staines A, Vincent CA. Int J Qual Health Care. 2022;34:mzac006.
Leadership engagement is key to achieving patient safety goals. When it comes to improvement and innovation, healthcare organizations must balance multiple, sometimes conflicting, aims, such as cost, clinician wellbeing, and patient safety. This commentary outlines how healthcare organizations can manage multiple complex aims in relation to improvement and innovation projects. Four principles of managing multiple aims and five key strategies for practical action are described.
Sujan M, Bilbro N, Ross A, et al. Appl Ergon. 2022;98:103608.
Failure to rescue refers to delayed or missed recognition of a potentially fatal complication that results in a patient’s death. This single-center study sought to more effectively manage deteriorating patients after emergency surgery and reduce failure to rescue rates. Researchers used the functional resonance analysis method (FRAM) to develop recommendations for strengthening organizational resilience. Recommendations included improving team communication, organizational learning, and relationships.

Rockville, MD: Agency for Healthcare Research and Quality; December 2021. AHRQ Publication No. 22-0009.

In consultation with AHRQ, the U.S. Department of Health and Human Services delivered a final report on effective strategies to improve patient safety and reduce medical errors to Congress. Required by the Patient Safety Act of 2005, the report was made available for public review and comment, and review by the National Academy of Medicine. It outlined several strategies to accelerate progress in improving patient safety, including using analytic approaches in patient safety research, measurement, and practice improvement to monitor risk; implementing evidence-based practices in real-world settings through clinically useful tools and infrastructure; encouraging the development of learning health systems that integrate continuous learning and improvement in day-to-day operations; and encouraging the use of patient safety strategies outlined in the National Action Plan by the National Steering Committee for Patient Safety.
Bell SK, Bourgeois FC, DesRoches CM, et al. BMJ Qual Saf. 2022;31:526-540.
Engaging patients and families in their own care can improve outcomes, safety, and satisfaction. This study brought patients, families, clinicians and experts together to identify patient-reported diagnostic process-related breakdowns. The group identified 7 categories, 40 subcategories, 19 contributing factors and 11 patient-reported impacts. Breakdowns were identified in each step of the diagnostic process.
Monazam Tabrizi N, Masri F. BMJ Open. 2021;11:e048036.
In this qualitative study, researchers interviewed 40 clinicians in high- and low-performing hospitals to better understand the barriers to effective organizational learning from medical errors. Findings from these interviews suggest that the primary barriers to active learning stem from social issues post-reporting – e.g., lack of trust or proactive engagement from management. The authors highlight the importance of fostering an organizational culture that encourages cooperation and collaboration between management and clinicians.
Azyabi A. Int J Environ Res Public Health. 2021;18:2466.
Accurate measurement of patient safety culture (PSC) is essential to improving patient safety. This review summarizes the results of 66 studies on PSC in hospitals. Multiple instruments were used to assess PSC, including the Hospital Survey on Patient Safety Culture (HSPSC) and the Safety Attitudes Questionnaire (SAQ). Teamwork and organization and behavioral learning were identified as critical factors impacting PSC and should be considered in future research.
Polancich S, Hall AG, Miltner RS, et al. J Healthc Qual. 2021;43:137-144.
The COVID-19 pandemic has disrupted many aspects of health care delivery, including how hospitals prevent common hospital-acquired conditions such as pressure injuries. Based on retrospective data, the authors of this study did not identify a longitudinal increase in hospital-acquired pressure injuries between March and July 2020. The authors discuss how prior organizational efforts to reduce hospital-acquired pressure injuries allowed their hospital to quickly adapt existing workflows and processes to respond to the COVID-19 pandemic.

Gandhi TK. NEJM Catalyst. Epub 2021 May 27.

The COVID-19 pandemic has shown a spotlight on bias, disparities, and inequity in the healthcare system. The author advocates using the same strategies to reduce inequities that were used to improve patient safety: 1) culture, leadership, and governance; 2) learning systems; 3) workforce; and 4) patient engagement.
Isherwood P, Waterson P. J Patient Saf Risk Manag. 2021;26:64-73.
Investigating adverse events and identifying contributing factors is essential to organizational learning and improving patient safety. The authors of this article use three different methodologies – root cause analysis (RCA), human factors analysis classification system (HFACS), and AcciMap (which places emphasis on multiple levels of decision making important to risk management) – to analyze one near miss incident and illustrate how different methodologies generate different systems-level recommendations.
Serou N, Sahota LM, Husband AK, et al. Int J Qual Health Care. 2021;33:mzab046.
High reliability organizations consistently examine and learn from failures. This systematic review identified several effective learning tools that can be adapted and used by multidisciplinary health care teams following a patient safety incident, including debriefing, simulation, crew resource management, and reporting systems. The authors concluded that these tools have a positive impact on learning if used soon after the incident but further research about successful implementation is needed.
Albutt AK, Berzins K, Louch G, et al. nt J Ment Health Nurs. 2021;30:798-810.
The UK’s National Health System has faced gaps in mental health care delivery affecting patient safety. Interviews with 14 mental health professionals identified several factors associated with patient safety in mental health service settings including safety culture, communication systems, service user factors, service process, and staff workload. Interventions to improve patient safety in mental health settings should be developed with these factors in mind.
Fröding E, Gäre BA, Westrin Å, et al. BMJ Open. 2021;11:e044068.
In Sweden, patient suicide following contact with a healthcare provider is regarded a potential case of patient harm and must be investigated and reported to the Swedish supervisory authority. This retrospective study analyzed reported cases across three timeframes and concluded the investigations were largely suited to fit the requirements of the supervisory authority rather than an opportunity for organizational learning to advance patient safety. A 2019 PSNet Spotlight Case highlights systems issues that contributed to a patient’s suicide following discharge from the Emergency Department.    
Goh HS, Tan V, Chang J, et al. J Nurs Care Qual. 2021;36:e63-e68.
Incident reporting systems are a common method for hospitals to detect patient safety events, but prior research has questioned whether these systems improve outcomes. Conducted in a nursing home, this study found that an existing incident reporting system redesigned to facilitate double-loop learning could improve nurses’ patient safety awareness and workplace practices, which could improve patient outcomes and safety.