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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 18399 Results
Sanghavi P, Chen Z. JAMA Netw Open. 2023;6:e2314822.
Underreporting patient safety events can hinder opportunities for improvement. Building on previous research, this study examined the association between nursing home characteristics and reporting patterns for two measures of nursing home care quality (falls with major injury and pressure ulcers). Findings suggest underreporting of both measures, and researchers identified an association between underreporting and the racial and ethnic composition of the nursing home facility. 
Schneider P, Lorenz A, Menegay MC, et al. Am J Obstet Gynecol MFM. 2023;5:100912.
Reducing maternal morbidity and mortality continues to be a patient safety priority in the United States. The article describes the implementation of a quality improvement initiative in Ohio to improve outcomes for patients with a severe hypertensive event during pregnancy or postpartum. Among 29 participating hospitals between July 2020 and September 2021, the researchers identified sustained improvements in timely and appropriate treatment for severe hypertension, timely follow-up appointment after hospital discharge, and patient education about urgent maternal warning signs across both non-Hispanic Black and White pregnant or postpartum people.
Jones BE, Sarvet AL, Ying J, et al. JAMA Netw Open. 2023;6:e2314185.
Pneumonia is one of the most common healthcare-acquired infections and can result in significantly longer lengths of stay and increased costs. In this retrospective study of more than six million hospitalized Veterans Health Administration patients, approximately 1 in 200 patients developed non-ventilator-associated hospital-acquired pneumonia (NV-HAP). Length of stay and mortality were significantly higher for patients with NV-HAP.

Grossman D, Joffe C, Kaller S, et al. Advancing New Standards in Reproductive Health, University of California, San Francisco; 2023.

Overarching policy decisions have the potential to impact systems of care and harm patients. This document reports the preliminary findings of a study examining 50 cases submitted where clinicians modified care standards in response to abortion access limitations. The changes affected the timeliness, quality, safety, cost, and complexity of care delivered to pregnant patients.
Hagström J, Blease CR, Kharko A, et al. Stud Health Technol Inform. 2023;302:242-246.
Patients are increasingly able to access their health record via electronic patient portals and many report finding errors in the record. This study asked adolescent (ages 15-19) patient portal users if they had identified errors or omissions in their record, and if so, did they report them to their provider. Approximately one-quarter of patients identified an error and 20% identified an omission. The majority of those patients did not report it to the clinic or healthcare provider.

Jaklevic MC. CNN. May 30, 2023.

Patient safety has long drawn from aviation safety strategies to inform improvement. This article examines the potential for transparency and learning should a National Patient Safety Board be established in the United States. Like the National Transportation Safety Board concept, the proposed agency would collect data on facilities where errors occurred, which is discussed as a barrier to acceptance of the safety board approach in health care.
Longo BA, Schmaltz SP, Barrett SC, et al. Jt Comm J Qual Patient Saf. 2023;Epub Apr 20.
Delivering health care in the home presents unique patient safety challenges. In this study, researchers identified significant associations between Joint Commission accreditation and measures of patient experience and patient safety with home health.
Caspi H, Perlman Y, Westreich S. Safety Sci. 2023;164:106147.
Near-misses or “good catches” are incidents that could have resulted in patient harm but did not due to it being caught at the last minute or through sheer luck. Reporting near-misses can help organizations learn and enact changes if necessary, but near-misses are not frequently reported. This study presents enablers and barriers to reporting near-misses.
Wimmer S, Toni I, Botzenhardt S, et al. Pharmacol Res Perspect. 2023;11:e01092.
Computerized physician order entry (CPOE) systems can prevent medication ordering and dispensing errors. This pre-post study compared medication safety outcomes for paper-based prescribing versus CPOE-based prescribing among pediatric patients at one German hospital. The researchers found that CPOE implementation resulted in fewer potentially harmful medication errors.
Khan A, Karavite DJ, Muthu N, et al. J Patient Saf. 2023;19:251-257.
For incidents to be properly addressed, incident reports must be appropriately identified and categorized by safety managers. This study compared the categorization of incidents as involving health information technology (HIT) or not involving HIT by specialists trained in HIT and patient safety and safety managers trained in traditional methods of health safety. Safety managers only agreed with the HIT specialist classification 25% and 75% of the time on incidents involving or not involving HIT, respectively. Increased education for safety managers on the interaction of HIT and patient safety may result in better classification of HIT-related incidents.

PULSE Center for Patient Safety Education & Advocacy. Second Monday of every month; 7:00 PM (eastern).

Patient advocates and caregivers play a valuable role in keeping patients safe. This reoccurring session provides a communication forum for individuals to discuss topics and shared experiences as they support patient safety. The next monthly session will be held June 12, 2023.
Alqenae FA, Steinke DT, Carson-Stevens A, et al. Ther Adv Drug Saf. 2023;14:204209862311543.
Medication errors and adverse drug events (ADE) are unfortunately common at hospital discharge. This study used the National Reporting and Learning System (NRLS) in England and Wales to identify contributing causes to medication errors and ADE. Patients over 65 were the most common age group and, of incidents with a stated level of harm, most did not result in any harm. Overall, most incidents occurred at the prescribing stage, but varied by patient age group. Most contributory factors were organizational (e.g., continuity of care between provider types), followed by staff, patient, and equipment factors.
Fisher L, Hopcroft LEM, Rodgers S, et al. BMJ Medicine. 2023;2:e000392.
Pharmacists play a critical role in medication safety. This article evaluated the impact of a pharmacist-led information technology intervention (PINCER) among a retrospective cohort of 56.8 million National Health Service (NHS) patients across 6,367 general practices between September 2019 and September 2021. Findings indicate that potentially dangerous prescribing (i.e., prescribing medications to patients without associated blood test monitoring, co-prescribing medications with adverse indications, prescribing medications to patients with certain comorbidities) was largely unaffected by the COVID-19 pandemic.
Delpino R, Lees-Deutsch L, Solanki B. BMJ Open Qual. 2023;12:e002047.
Following the 2013 release of the Report of The Mid Staffordshire NHS Foundation Trust inquiry, National Health Service (NHS) Trusts have made substantial efforts to increase staffs’ willingness to speak up about patient safety concerns. One method is the creation of confidential resources who provide staff support: Freedom to Speak Up Guardians (FTSUG) and Confidential Contacts (CC). This study explored perspectives of FTSUG and CC on how they best support staff and how leaders can encourage speaking up behavior.
Zaitoun RA, Said NB, de Tantillo L. BMC Nurs. 2023;22:173.
Nurses play an important role in ensuring patient safety. This systematic review identified 16 studies examining the relationship between nursing competence and safety culture. The researchers identified several gaps in the evidence, including the need for rigorous research measuring the association between safety culture and nursing safety competencies and evaluating the effect of nursing safety competency on safety culture scores.
Larsson F, Strömbäck U, Rysst Gustafsson S, et al. Int J Qual Stud Health Well-being. 2023;18:2216018.
Patients expect to "feel safe" in healthcare settings. This concept analysis describes defining attributes (participation, control, presence) of patients in the perioperative environment. Through a series of cases that include all, some, or none of the safety attributes, the authors illustrate the concept of patients "feeling safe" in the perioperative environment.
Bourne RS, Jeffries M, Phipps DL, et al. BMJ Open. 2023;13:e066757.
Patients transitioning from the intensive care unit (ICU) to the general ward are vulnerable to medication errors. This qualitative study included medical staff and clinical pharmacists from hospital wards and ICUs to identify factors that contribute to medication safety or adverse events at times of transition. Lack of communication between provider types (e.g., nurse and pharmacist) and time pressure considerations had negative effects on medication safety. Ward rounds and safety culture had positive effects.
Wilson E, Daniel M, Rao A, et al. Diagnosis (Berl). 2023;10:68-88.
Clinical decision-making is a complex process often involving interactions with multiple team members, processes, and systems. Using distributed cognition theory and qualitative synthesis, this scoping review including 37 articles identified seven themes addressing how distribution of tasks influences clinical decision-making in acute care settings The themes included information flow, task coordination, team communication, situational awareness, electronic health record (EHR) design, systems-level error, and distributed decision-making.