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.

Search All Content

Clear all filter(s)

Displaying 1 - 20 of 1276 Results

The relationship between job stress and patient safety culture among nurses: a systematic review.

Save to Library

Zabin LM, Zaitoun RSA, Sweity EM, et al. BMC Nurs. 2023;22:39.

Fostering a culture of safety is an essential component of improving patient safety and health care quality. This systematic review of seven articles identified a negative relationship between job-related stress among nurses and patient safety culture. Studies also reported that factors such as fatigue, workload, burnout, and workplace violence contribute to job-related stress and resulted in decreased patient safety culture.

The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis

Save to Library

Patient Safety Innovation March 15, 2023

During a time of unprecedented patient volume and clinical uncertainty, a diverse team of health system administrators and clinicians within the University of Pennsylvania Health System quickly investigated, updated, and disseminated airway management protocols after several airway safety incidents occurred among COVID-19 patients who were mechanically ventilated. Based on this experience, the team created the I-READI framework as a guide for healthcare systems to prepare for and quickly respond to quality and safety crises.¹

Managing safety in perioperative settings: strategies of meso-level nurse leaders.

Save to Library

Brooks JV, Nelson-Brantley H. Health Care Manage Rev. 2023;48:175-184.

Effective nurse managers support a culture of safety and improved patient outcomes. This study explores strategies implemented by meso-level nurse leaders - nurse managers between executive leadership and direct care nurses – to enable a culture of safety in perioperative settings. Four strategies were identified: (a) recognizing the unique perioperative management environment, (b) learning not to take interactions personally, (c) developing "super meso-level nurse leader" skills, and (d) appealing to policies and patient safety.

Coworker abuse in healthcare: voices of mistreated workers.

Save to Library

Evans WR, Mullen DM, Burke-Smalley L. J Health Organ Manag. 2023;Epub Jan 24.

Nurses have reported experiencing horizontal abuse and bullying (e.g., bullying by other nurses) and perceive that workplace bullying results in errors. Using posts from the social media site Reddit, researchers sought to understand who perpetrates the abuse, types of abuse, perceived reasons, nurses’ responses, and location of abuse. Organizational strategies such as mindfulness, reshaping the culture, bystander interventions and explicit leadership support are suggested to prevent nurse co-worker abuse.

Curated Libraries

Value and Patient Safety

March 8, 2023

Value as an element of patient safety is emerging as an approach to prioritize and evaluate improvement actions. This library highlights resources that explore the business case for cost effective, efficient and impactful efforts to reduce medical errors.

Hospital discharge and readmission.

Save to Library

Alper E, O'Malley TA, Greenwald J. UpToDate. February 3, 2023.

This review examines hospital discharge, details elements of the process that can increase risk of readmission, and reveals interventions to improve safety.

Lessons learned from the RaDonda Vaught ruling.

Save to Library

Bilski J. Outpatient Surgery. February 2023;16-21

The concept of just culture was challenged in a high-profile medication error resulting in criminal charges for a nurse. This dialogue shares insights on the impact of the case on nurses, their profession, and patient safety.

Registered nurses' efforts to ensure safety for home-dwelling older patients.

Save to Library

Lindberg C, Fock J, Nilsen P, et al. Scand J Caring Sci. 2022.

Providing in-home care for home-dwelling adults presents unique patient safety challenges. This qualitative study with 13 registered nurses in Sweden explored how nurses ensure safe home health care among home-dwelling older patients. Findings highlight the importance of continuity of care, trust between patients, caregivers, and nurses, and adapting safety requirements to meet environmental conditions and maintain a sense of home.

ISMP Medication Safety Intensive.

Save to Library

Institute for Safe Medication Practices. April 13-14, 2023.

This virtual workshop will explore tactics to ensure medication safety, including strategic planning, risk assessment, and Just Culture principles.

Factors differentiating nursing homes with strong resident safety climate: a qualitative study of leadership and staff perspectives.

Save to Library

Engle RL, Gillespie C, Clark VA, et al. J Gerontol Nurs. 2023;49:13-17.

Nurses’ willingness to speak up about resident safety concerns varies based on anticipated leadership response and support. Clinical and non-clinical staff at six Department of Veterans Affairs (VA) nursing homes with diverse safety climate ratings (high, medium, low) were interviewed to understand the association between resident safety and safety climate. Staff at high safety climate facilities described open communication and leadership responsiveness as contributors to a strong safety climate and willingness to speak up.

Speaking up during the COVID-19 pandemic: nurses' experiences of organizational disregard and silence.

Save to Library

Abrams R, Conolly A, Rowland E, et al. J Adv Nurs. 2023;Epub Jan 16.

Speaking up about safety concerns is an important component of safety culture. In this study, nurses in a variety of fields shared their experiences with speaking up during the COVID-19 pandemic. Three themes emerged: the ability to speak up or not, anticipated consequences of speaking up, and responses, or lack thereof, from managers.

Nursing home patient safety culture perceptions among licensed practical nurses.

Save to Library

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.

Exploring nursing-sensitive events in home healthcare: a national multicenter cohort study using a trigger tool.

Save to Library

Nilsson L, Lindblad M, Johansson N, et al. Int J Nurs Stud. 2022;138:104434.

Nurse-sensitive outcomes are important indicators of nursing safety. In this retrospective study of 600 patient records from ten Swedish home healthcare organizations, researchers found that 74% of patient safety incidents were classified as nursing-sensitive and that the majority of those events were preventable. The most common types of nursing-sensitive events were falls, pressure injuries, healthcare-associated infections, and incidents related to medication management.

Self-reported gaps in care coordination and preventable adverse outcomes among older adults receiving home health care.

Save to Library

Sterling MR, Lau J, Rajan M, et al. J Am Geriatr Soc. 2022;Epub Dec 5.

Home healthcare is common among older adults, who are often vulnerable to patient safety events due to factors such as medical complexity. This cross-sectional study of 4,296 Medicare patients examined the relationship between receipt of home healthcare services, perceived gaps in care coordination, and preventable adverse outcomes. The researchers found that home healthcare was not associated with self-reported gaps in care coordination, but was associated with increases in self-reported preventable drug-drug interactions (but not ED visits or hospital admissions).

Implementation of peer messengers to deliver feedback: an observational study to promote professionalism in nursing.

Save to Library

Baldwin CA, Hanrahan K, Edmonds SW, et al. Jt Comm J Qual Patient Saf. 2023;49:14-25.

Unprofessional and disruptive behavior can erode patient safety and safety culture. The Co-Worker Observation System (CORS), a peer-to-peer feedback program previously used with physicians and advance practice providers, was implemented for use with nurses in three hospitals. Reports of unprofessional behavior submitted to the internal reporting system were evaluated by the CORS team, and peer-to-peer feedback was given to the recipient. This pilot study demonstrated that the implementation bundle can be successful with nursing staff.

Unsafe by design: infusion task reallocation and safety perceptions in U.S. hospitals.

Save to Library

Pratt BR, Dunford BB, Vogus TJ, et al. Health Care Manage Rev. 2022;48:14-22.

Organizational pressures sometimes lead to redeployment or task reallocation such as shifting infusion tasks from specialty nurse teams to generalist nurses. This survey of nurses in the United States found that infusion task reallocation led to increased job demands and reduced resources, thereby contributing to lower perceived organizational safety.

Strategies for a safe interhospital transfer with an intubated patient or where readiness for intubation is needed: a critical incidents study.

Save to Library

Almqvist D, Norberg D, Larsson F, et al. Intensive Crit Care Nurs. 2022;74:103330.

Interhospital transfers pose a serious risk to patients. In this study, nurse anesthetists and intensive care nurses described strategies to ensure safe transport for patients who are intubated or who may require intubation. Strategies include clear and adequate communication between providers prior to transport, stabilizing and optimizing the patient’s condition, and ensuring that appropriate drugs and equipment are prepared and available.

A framework for assessing reasoning about controversial end-of-life clinical decisions.

Save to Library

WebM&M Case December 14, 2022

A 65-year-old man with metastatic liver disease presented to the hospital with worsening abdominal pain after a partial hepatectomy and development of a large ventral hernia. Imaging studies revealed perforated diverticulitis. A goals-of-care discussion was led by the palliative care service; the patient and his designated decision-makers chose to pursue non-operative management of diverticulitis.

Guidelines in Practice: prevention of unintentionally retained surgical items.

Save to Library

Cochran K. AORN J. 2022;116:427-440.

AORN revised its Guideline for prevention of unintentionally retained surgical items in late 2021. This article focuses on concepts and recommendations specific to counting procedures, reconciling discrepancies, technology, and education.

Interprofessional clinical event debriefing-does it make a difference? Attitudes of emergency department care providers to INFO clinical event debriefings.

Save to Library

Rose SC, Ashari NA, Davies JM, et al. CJEM. 2022;24:695-701.

Debriefing is used to enhance individual and team communication and to facilitate real-time learning opportunities after a critical event. This study evaluated a charge nurse-facilitated clinical debriefing program used in Emergency Departments (EDs) in Alberta, Canada. Qualitative analyses identified several themes underscoring the impact of the debriefing program – the impacts on clinical practice and patient care, impacts on psychological safety and teamwork, stress management, and the emotional acknowledgement after critical events – and barriers to debriefing.

The PSNet Collection: All Content

Search All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

The PSNet Collection: All Content

Search All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Case

Continue as a Guest

Continue Logged In

Submit Your Case

Continue as a Guest

Already have a PSNet

Account?

New Users