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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 196 Results
Perspective on Safety August 30, 2023

This piece focuses on the importance of patient safety following the end of the public health emergency and how organizations can move beyond the pandemic.

This piece focuses on the importance of patient safety following the end of the public health emergency and how organizations can move beyond the pandemic.

Patricia McGaffigan

Patricia McGaffigan is the Vice President for Safety Programs at the Institute for Healthcare Improvement and President of the Certification Board for Professionals in Patient Safety. We spoke to Patricia about patient safety trends and how patient safety will move beyond the pandemic.

Perspective on Safety July 31, 2023

This piece focuses on the importance of building the capacity of the workforce and organizations for patient safety using patient safety education.

This piece focuses on the importance of building the capacity of the workforce and organizations for patient safety using patient safety education.

Regina Hoffman

Regina Hoffman is the executive director of the Pennsylvania Patient Safety Authority. We spoke to her about her experience in collaborative learning, sharing information across healthcare facilities, and patient safety education.

Pisani AR, Boudreaux ED. Focus (Am Psychiatr Publ). 2023;21:152-159.
Identifying patients with suicidal ideation can be a challenging clinical problem in the emergency department. These authors use a systems-based approach to identify missed opportunities to prevent suicide and present a systems approach to suicide prevention including three core domains – a culture of safety and prevention, applying best practices and policies for prevention in systems, and workforce education and development.
Cox GR, Starr LM. J Healthc Manag. 2023;68:151-157.
Becoming a high-reliability organization (HRO) to improve patient safety is a goal of the Veterans Heath Administration (VHA). This commentary describes the VHA's implementation strategy and progress since 2019 at the patient, employee, and organizational levels. The three pillars of the VHA's HRO strategy are leadership commitment, a culture of safety, and continuous process improvement. Challenges associated with the COVID-19 pandemic are also discussed.
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.
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.

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.
Bates DW, Williams EA. J Allergy Clin Immunol Pract. 2022;10:3141-3144.
Electronic health records (EHRs) are key for the collection of patient care data to inform overarching risk management and improvement strategies. This article discusses the adoption of EHRs as tools supporting patient safety and highlights the need for an expanded technology infrastructure to continue making progress.
Brattebø G, Flaatten HK. Curr Opin Anaesthesiol. 2023;36:240-245.
Latent errors or conditions are subtle and can be difficult to identify before an incident occurs. This commentary calls for moving from the reactive "bad apple" paradigm to a proactive just culture, where errors and near misses serve as organizational learning opportunities, and not as a time for individual discipline.
Merchant NB, O’Neal J, Dealino-Perez C, et al. Am J Med Qual. 2022;37:504-510.
The goal for health care organizations to attain high reliability is established but elusive. This article shares insights drawn from a Veterans’ Health system effort to support high reliability. The approach used centered on five components focusing on leadership, data systems, implementation, training, and safety culture.
Borycki EM, Kushniruk AW. Healthc Manage Forum. 2023;51:212-221.
Health technology has improved many aspects of care, but can also introduce new safety concerns that require active monitoring and improvement. This commentary describes how learning health systems can improve the safety of new technologies, such as hiring health informaticists and collaborations with health authorities and vendors.
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.
Curated Libraries
October 10, 2022
Selected PSNet materials for a general safety audience focusing on improvements in the diagnostic process and the strategies that support them to prevent diagnostic errors from harming patients.
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.