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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 12517 Results
Tawfik DS, Adair KC, Palassof S, et al. Jt Comm J Qual Patient Saf. 2022;Epub Dec 23.
Leadership across all levels of a health system plays an important role in patient safety. In this study, researchers administered the Safety, Communication, Operational, Reliability, and Engagement (SCORE) survey to 31 Midwestern hospitals to evaluate how leadership behaviors influenced burnout, safety culture, and engagement. Findings indicate that local leadership behaviors are strongly associated with healthcare worker burnout, safety climate, teamwork climate, workload, and intentions to leave the job.
Dykes PC, Curtin-Bowen M, Lipsitz S, et al. JAMA Health Forum. 2023;4:e225125.
Patient falls are associated with poorer clinical outcomes, and increased costs to the health system. This study describes the economic costs of implementing the Fall Tailoring Interventions for Patient Safety (Fall TIPS) Program in eight American hospitals. Results show the Fall TIPS program reduced falls by 19%, avoiding over $14,000 of costs per 1,000 patient days.
Hawkins SF, Morse JM. Glob Qual Nurs Res. 2022;9:233339362211317.
Medication administration is a complex set of tasks completed many times per day for hospitalized patients. This study captures the turbulence of nursing work, the nursing environment, and how that impacts patient safety. The results suggest organizations should re-evaluate current attempts at improving medication administration safety and include nurses in identifying new solutions.
Chew MM, Rivas S, Chesser M, et al. J Patient Saf. 2023;19:23-28.
Provision of enteral nutrition (EN) is a specialized process requiring careful interdisciplinary teamwork. After discovering significant issues with ordering, administration, and documentation of EN, this health system updated its workflows to improve safety. EN therapies were added to the electronic medication administration record (MAR) and the barcoding system was updated. After one year, all EN orders were barcode scanned and nearly all were documented as given or included a reason why they were not given.
Krombach JW, Zürcher C, Simon SG, et al. Anaesth Crit Care Pain Med. 2022;42:101186.
Checklists have been highlighted as a cognitive aid to decrease omissions of care in surgery and other routine and critical events. This study evaluated a pre- and post-anesthesia induction checklist to determine the omission rate and impact on patient safety. Use of the checklist reduced omission rates significantly during both pre- and post-induction periods. However omission remained high at 32% and 40%, respectively and use of the checklists remained low.
Wells JM, Walker VP. Health Promot Pract. 2023:152483992211451.
Addressing racism in healthcare is a patient safety priority. This article discusses how an active presence by hospital threat management systems (e.g., hospital-employed security, local law enforcement personnel) in pediatric emergency departments (EDs) can help ensure patient safety but also contributes to unsafe care due to racial stereotypes and threat perception among minority patients and caregivers. The authors outline patient-centered strategies at the individual-, intra-organizational-, and extra-organizational levels for responding to disruptive and violent events.
Healy A, Davidson C, Allbert J, et al. Am J Obstet Gynecol. 2022;Epub Dec 5.
The demand for, and acceptance of, telemedicine solutions to provide services has grown substantially in recent years as safety profiles for the services are being defined. This guideline examines its use in pregnancy-related care, discusses the benefits and suggests actions to ensure patient safety during these encounters such as development of appropriate metrics and methods for vital-sign monitoring.
Weaver SH, de Cordova PB, Ravichandran A, et al. J Nurs Care Qual. 2022;Epub Dec 7.
Nurse work environment has been linked to perceived safety culture and job satisfaction. This cross-sectional survey of licensed practical nurses (LPNs) in New Jersey found lower job satisfaction and perceived patient safety culture among LPNs working in nursing homes compared to LPNs working in other settings.
Corby S, Ash JS, Florig ST, et al. J Gen Intern Med. 2022;Epub Nov 16.
Medical scribes are increasingly being utilized to reduce the time burden on clinicians for electronic health record (EHR) documentation. In this secondary analysis, researchers identified three themes for safe use of medical scribes: communication aspects, teamwork efforts, and provider characteristics.

Goldstein J. New York Times. January 23, 2023.

Active errors are evident when they occur, yet systemic weaknesses, if not addressed, allow them to repeat. This story examines poor epidural methods of one clinician that coincided with lack of organizational practitioner monitoring, unequitable maternal care for black women and clinician COVID fatigue to contribute to patient death.

Oakbrook Terrace, IL: Joint Commission and National Quality Forum: January 23, 2023. 

The annual Eisenberg Award recognizes leaders and organizations who have made substantial contributions toward patient safety and quality improvement. The 2022 honorees are Jason S. Adelman, MD, MS, North American Partners in Anesthesia (NAPA) and Parkland Health, Dallas County, Texas. The awards will be presented at the National Quality Forum's annual conference on February 20, 2023, in Washington, DC.
Kwon CS, Duzyj C. Am J Perinatol. 2022;Epub Dec 30.
Effective teamwork is critical for patient safety and numerous training strategies exist for improving team dynamics. The labor and delivery unit of an American hospital offered Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) training to all physicians and nurses on the ward, and assessed perceptions of teamwork and safety both before and six months after training. Results were mixed, and physician and nurse perceptions of safety significantly differed.
Reyes AM, Royan R, Feinglass J, et al. JAMA Surg. 2023;Epub Jan 18.
Delays in diagnosis and treatment can lead to poor outcomes. In this population-based retrospective longitudinal study using inpatient and emergency department discharge data from four states, researchers found that non-Hispanic Black patients were at higher risk for delayed diagnosis of appendicitis compared to White patients. This increased risk for delayed diagnosis translated into higher risks for postoperative 30-day readmission rates. The researchers found that this risk was mitigated when Black patients received care at hospitals serving a more diverse patient population.

Grimm CA. Washington DC: Office of the Inspector General; Nov 2022. Report no. OEI-07-20-00500.

Misdiagnosis can result in inappropriate medication use. This report examined the overuse of antipsychotics in nursing homes and resident harms. These recommendations from the U.S. Department of Health and Human Services Office of the Inspector General include heightened evaluation and oversight of medication use and better documentation of diagnosis with medication orders as avenues for improvement.
Classen DC, Longhurst CA, Thomas EJ. NPJ Digit Med. 2023;6:2.
Artificial Intelligence (AI) is used in an increasing range of health care situations to address a variety of care needs. This commentary examines the impact of AI on patient safety, in diagnosis, and on the limitations of AI that affect reliability.

Institute for Healthcare Improvement. Gaylord National Resort and Convention Center, National Harbor, MD, May 22–24, 2023.

This annual conference will host pre-session workshops, panels, and presentations covering a variety of patient safety topics that align with the national agenda for patient safety improvement such as learning systems and leadership. Sessions will take place in-person.

Järvinen TLN, Rickert J, Lee MJ, et al. Clin Orthop Relat Res. 2013-2023.

This quarterly commentary explores a wide range of subjects associated with patient safety, such as the impact of disruptive behavior on teams, the value of apologies, and safety challenges due to COVID-19. Older materials are available online for free.
Food and Drug Administration and Institute for Safe Medication Practices. Plymouth Meeting, PA; Institute for Safe Medication Practices; January 2023.
Mistakes associated with look-alike medication names are a safety concern in health care. Tall man, or mixed case, lettering is one recommended strategy to reduce confusion associated with similarities in drug names. This list includes medications recognized by clinicians and professional organizations as those suited for the application of mixed case lettering to make their use safer.
Bates DW, Levine DM, Salmasian H, et al. New Engl J Med. 2023;388:142-153.
An accurate understanding of the frequency, severity, and preventability of adverse events is required to effectively improve patient safety. This study included review of more than 2,800 inpatient records from 11 American hospitals with nearly one quarter having at least one preventable or not preventable adverse event. Overall, approximately 7% of all admissions included at least one preventable event and 1% had a severity level of serious or higher.
Baluyot A, McNeill C, Wiers S. Patient Safety. 2022;4:18-25.
Transitions from hospital to skilled nursing facilities (SNF) remain a patient safety challenge. This quality improvement (QI) project included development of a structured handoff tool to decrease the wait time for receipt of controlled medications and intravenous (IV) antibiotics and time to medication administration. The project demonstrated significant improvements in both aims and can be replicated in other SNFs.