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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 246 Results
Boudreaux ED, Larkin C, Vallejo Sefair A, et al. JAMA Psych. 2023;Epub May 17.
Patients who present to the emergency department (ED) with suicidal ideation can benefit from ED-initiated interventions, but interventions can be difficult to implement and maintain. This research builds on a 2013 study, describing the quality improvement (QI) methods used to implement the Emergency Department Safety Assessment and Follow-up Evaluation 2 (ED-SAFE 2) trial. The QI approach was successful in reducing death by suicide and suicide-related acute care during the study period.
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.
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.

Washington, DC: VA Office of the Inspector General; March 29, 2023. Report no. 21-03680-80.

Care systems for alcohol use disorder (AUD) patients are suboptimal. This report examines the case of a patient with AUD whose emergency care was mismanaged, uncoordinated, and incomplete, contributing to his death two days after discharge. The safety recommendations shared include improving discharge planning, assessment, and consideration of mental health conditions when caring for AUD patients.
Gorman LS, Littlewood DL, Quinlivan L, et al. BJPsych Open. 2023;9:e54.
Families can offer a unique perspective to improve patient care. This study describes ways families keep patients safe from suicide during crisis resolution home treatment in the UK. Families increased safety by hiding medications or distracting patients who were in crisis. Challenges to involving families are detailed, as well as ways organizations can overcome those challenges.
Crowley N. Prim Care. 2023;50:89-101.
Patients living with obesity face increased health risks due to poor equipment availability and provider bias. This article details the types of bias (i.e., implicit and explicit) experienced by people with obesity and its impact, suggestions for person-first language, and ways for clinicians to engage patients in discussions about their weight.

D'Ambrosio A. MedPage Today. March 31, 2023.

Maternal health is challenged across social strata but notably amongst populations of color, economic disparity, and social minority. This article discusses barriers mothers face trying to manage substance use disorders during pregnancy and after birth due to system problems and stigma.

Farnborough, UK: Healthcare Safety Investigation Branch; March 2023.

Patient suicide is a sentinel event. This report examines a suicide incident that identified problems with risk assessment and identification, family engagement, and medication management in the context of mental health provision when supporting patients in psychological distress.
Perspective on Safety March 29, 2023

This piece focuses on perinatal mental health and efforts to improve maternal safety.   

This piece focuses on perinatal mental health and efforts to improve maternal safety.   

Christie Allen

Christie Allen is the Senior Director of Quality Improvement at the American College of Obstetrics and Gynecology (ACOG). We spoke to her about her experience in maternal safety and improving perinatal mental healthcare, which is care for mental health conditions during pregnancy and the twelve months following delivery

WebM&M Case March 29, 2023

An adult woman with a history of suicidal ideation was taking prescribed antidepressants, but later required admission to the hospital after overdosing on her prescribed medications. A consulting psychiatrist evaluated the patient but recommended sending her home on a benzodiazepine alone, under observation by her mother.

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.