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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 237 Results
Phelan SM, Salinas M, Pankey T, et al. Ann Fam Med. 2023;21:s56-s60.
Stigma can prevent patients from seeking necessary mental health care. In this study, researchers conducted qualitative interviews with patients and health care providers to assess mental health stigma and barriers to use of integrated behavioral health (IBH) in primary care settings. Participants identified the importance of normalizing discussions about mental health care and patient-centered communication.

Washington, DC: VA Office of the Inspector General; February 2, 2023. Report no. 22-01363-52.

Gaps in care for psychologically vulnerable patients can result in harm to family members and self-harm. This report examines organizational failures in responding to staff and clinical leaders’ concerns regarding access, triage, and care continuity for mental health patients. Recommendations for improvement include same-day access to appropriate specialty care, medication management, and risk documentation.
Crapanzano KA, Deweese S, Pham D, et al. J Behav Health Serv Res. 2023;50:236-262.
Patients with mental illness may receive lower quality healthcare care than patients without mental illness. In this review of implicit and explicit biases of healthcare providers, the majority demonstrated unfavorable clinical decisions towards patients with mental illness. A prior WebM&M describes how diagnostic overshadowing of a patient with substance use disorder led to undertreatment of a cardiovascular condition.
Vargas V, Blakeslee WW, Banas CA, et al. PLoS ONE. 2023;18:e0279903.
Medication reconciliation can help identify medication discrepancies during transitions of care. This study examined the impact of a complete medication history database to support pharmacist-led medication reconciliation and identification of medication discrepancies during the admission process for patients at one psychiatric hospital. A retrospective analysis identified 82 medication errors; 90% of these errors – primarily dosage discrepancies and omissions – could have led to patient harm if not corrected through pharmacist intervention.
Curated Libraries
January 19, 2023
The Primary-Care Research in Diagnosis Errors (PRIDE) Learning Network was a Boston-based national effort to improve diagnostic safety. Hosted by the State of Massachusetts’ Betsy Lehman Center, it was led by the Harvard Brigham and Women’s Center for Patient Safety Research and Practice with funding from the Gordon and Betty Moore Foundation. ...
Averill P, Vincent CA, Reen G, et al. Health Expect. 2023;26:51-63.
Patient safety research on inpatient psychiatric care is expanding, but less is known about outpatient mental health patient safety. This review of safety in community-based mental health services revealed several challenges, including defining preventable safety events. Additionally, safety research has focused on harm caused by the patient instead of harm caused by mental health services, such as delays in access or diagnosis.
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.
Krvavac S, Jansson B, Bukholm IRK, et al. Int J Environ Res Public Health. 2022;19:10686.
Inpatient suicide is sentinel event. This study examined treatment patterns among patients undergoing inpatient or outpatient psychiatric treatment who died by suicide. The research team found that patients who were primarily treated with medications were less likely to be sufficiently monitored, whereas patients who received both psychotherapy and medication were more likely to receive inadequate treatment.
Fröding E, Vincent C, Andersson-Gäre B, et al. Arch Suicide Res. 2022;Epub Oct 19.
Earlier research shows many investigations into suicide deaths are conducted to fulfill regulatory requirements, rather than to improve suicide-prevention interventions. This review identified six problems with investigations (e.g., failure to consider deeper system perspective) and proposed a new model of investigation which considers suicide a patient harm.
Riblet NB, Varela M, Ashby W, et al. Jt Comm J Qual Patient Saf. 2022;48:503-512.
Preventing suicide among patients with a mental health diagnosis is a National Patient Safety goal. This study evaluated the impact of the WHO Brief Intervention and Contact (BIC) Program on suicide after psychiatric discharge at six Department of Veterans Affairs (VA) medical centers. After implementation, nearly 82% of patients exhibited positive treatment engagement. Participating healthcare staff reported that the program was easy to use and implement but noted that insufficient staffing and patient loss-to-follow-up can impede program success. A previous WebM&M case and commentary discusses suicide after discharge.
FitzGerald C, Mumenthaler C, Berner D, et al. BMC Med Ethics. 2022;23:86.
Patients with obesity and mental illness face both explicit and implicit bias that negatively impact their healthcare. This study of psychiatric and general internal medicine physicians analyzed implicit and explicit bias towards patients with mental illness and/or obesity. Results varied by specialty, physician age, gender, and experience level.
Patient Safety Primer September 27, 2022
Burnout is an occupational phenomenon that is highly prevalent among health care professionals. Current work focuses on understanding burnout and clinician well-being as system-level concerns that can adversely influence safety, quality, and organizational performance.

Rockville, MD: Substance Abuse and Mental Health Services Administration; 2022.  SAMHSA Publication No. PEP22-06-02-005.

Behavioral health workers are particularly susceptible to burnout, which sets the stage for unsafe care. This guide highlights organizational strategies to amend six thematic conditions in the behavioral health setting that degrade worker wellbeing: workload; control; reward, promotion, and career development; community; fairness; and values.
Zipperer L, Ryan R, Jones B. J Patient Saf Risk Manag. 2022;27:201-208.
Implicit biases and stigma can negatively impact health care provided to patients with substance use disorders such as alcohol use disorder (AUD). This narrative review concluded that patients with AUD are frequently undiagnosed and not appropriately referred for treatment or treated. The authors cite barriers to effective care for patients with AUD, including poor integration and coordination between medical care and behavioral health care in the United States.
Berg SH, Rørtveit K, Walby FA, et al. BMC Health Serv Res. 2022;22:967.
Inpatient suicides are considered a never event. Based on patient and provider interviews and a literature review, this paper describes the development of resilience in inpatient psychiatric settings. The main theme is establishment of relationship of trust between patients and providers.
Ramsey L, McHugh SK, Simms-Ellis R, et al. J Patient Saf. 2022;18:e1203-e1210.
Patients and families can contribute unique insights into medical errors. This qualitative evidence review concluded that patients and families value involvement in patient safety incident investigations but highlight the importance of addressing the emotional aspects of care (e.g., timely apology, prioritizing trust and transparency). Healthcare staff perceived patient and family involvement in investigations to be important, but cited several barriers (e.g., staff turnover, fears of litigation) to effective investigations.
Barnes T, Fontaine T, Bautista C, et al. J Patient Saf. 2022;18:e704-e713.
Patient safety event taxonomies provide a standardized framework for data classification and analysis. This taxonomy for inpatient psychiatric care was developed from existing literature, national standards, and content experts to align with the common formats used by the institution’s event reporting system. Four domains (provision of care, patient actions, environment/equipment, and safety culture) were identified, along with categories, subcategories, and subcategory details.
Shiner B, Gottlieb DJ, Levis M, et al. BMJ Qual Saf. 2022;31:434-440.
Previous research has emphasized suicide prevention in inpatient mental health settings, but less is known about suicide in outpatient settings. Using longitudinal data from 2013 to 2017, this study found no relationship between overall quality of outpatient mental healthcare and suicide rates among patients treated by the Veterans Health Administration healthcare system.