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 2302 Results

Maternal Safety and Perinatal Mental Health

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Perspective on Safety March 29, 2023

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

Anesthesiology patient handoff education interventions: a systematic review.

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Riesenberg LA, Davis R, Heng A, et al. Jt Comm J Qual Patient Saf. 2022;Epub Dec 15.

Anesthesiologists frequently hand off care of complex, often unstable patients, which can introduce patient safety risks. This systematic review examined the education components of studies seeking to improve anesthesiology handoffs. The authors identified marked heterogeneity in the use of established curriculum development best practices and concluded that more than half of the medical education interventions were of low quality. The authors identify challenges that could be addressed to improve future educational interventions.

Effect of patient safety education interventions on patient safety culture of health care professionals: systematic review and meta-analysis.

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Agbar F, Zhang S, Wu Y, et al. Nurse Educ Pract. 2023;67:103565.

Health systems seeking to improve patient safety culture (PSC) implement myriad of educational programs for their staff. This review identified 16 studies of PSC education programs that included before and after surveys or intervention and control groups. Results were generally positive, but repeated trainings may be needed to sustain the change. Additionally, based on the reporting using the AHRQ Hospital Survey of Patient Safety Culture (HSOPS), a culture of blame remained a pervasive problem despite improvements in other components of patient safety culture in many hospitals.

Why hospitals still make serious medical errors—and how they are trying to reduce them.

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Landro L. Wall Street Journal. March 12, 2023.

Patient harm from health care is persistent despite decades of effort to address problems that degrade care. This article discusses the potential that improved technology use has in reducing medication errors, falls, surgical errors, and high-risk hospital-acquired infections.

The influence of professional identity on how the receiver receives and responds to a speaking up message: a cross-sectional study.

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Barlow M, Watson B, Jones EW, et al. BMC Nurs. 2023;22:26.

Healthcare providers may decide to speak up or remain silent about patient safety concerns based on the expected response of the recipient. In this study, clinicians from multiple disciplines responded to two hypothetical speaking up scenarios to explore the impact of communication behavior and speaker characteristics (e.g., discipline, seniority, presence of others) on the recipient’s intended response. Each of the factors played a role in how the clinician received the message and how they would respond.

Reducing diagnostic errors in the emergency department at the time of patient treatment.

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Petts A, Neep M, Thakkalpalli M. Emerg Med Australas. 2022;Epub Dec 5.

Misinterpretation of radiology test results can contribute to diagnostic errors and patient harm. Using a set of 838 pediatric and adult radiographic examinations, this retrospective study found that radiographers’ interpretations can complement emergency clinicians’ interpretations and increase accuracy compared to emergency clinician interpretation alone.

Errors in medicine: punishment versus learning medical adverse events revisited - expanding the frame.

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Brattebø G, Flaatten HK. Curr Opin Anaesthesiol. 2023;36:240-245.

Latent errors or conditions are subtle and can be difficult to identify before an incident occurs. This commentary calls for moving from the reactive "bad apple" paradigm to a proactive just culture, where errors and near misses serve as organizational learning opportunities, and not as a time for individual discipline.

Quality and safety: learning from the past and (re)imagining the future.

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Bates DW, Williams EA. J Allergy Clin Immunol Pract. 2022;10:3141-3144.

Electronic health records (EHRs) are key for the collection of patient care data to inform overarching risk management and improvement strategies. This article discusses the adoption of EHRs as tools supporting patient safety and highlights the need for an expanded technology infrastructure to continue making progress.

Exploration of ward-based nurses' perspectives on their preparedness to recognize clinical deterioration: a scoping review.

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Mikhail J, King L. J Patient Saf. 2023;19:99-109.

Early recognition of warning signs of deterioration is key to activating the rapid response system (RRS) and prevention of serious adverse events. This review sought to understand how preparedness of ward-based nurses supports recognition of early warning signs and activation of RRS. Themes include knowledge of criteria to activate the RRS and deference to organizational hierarchy.

Frequency of medication administration timing error in hospitals: a systematic review.

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Pullam T, Russell CL, White-Lewis S. J Nurs Care Qual. 2023;38:126-133.

Medication timing errors can lead to too-frequent or missed doses of medications and cause patient harm. This systematic review including 23 articles found that medication administration timing errors (defined in the majority of studies as administration greater than 60 minutes before or after the scheduled time) occur in up to 72.6% of medication administration errors.

Addressing Medical Gaslighting to Improve Maternal Health—Together.

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Oregon Patient Safety Commission: 2023.

Gaslighting has been identified as a contributor to maternal mortality and morbidity. This toolkit of compiled resources aims to help inform organizational activities to establish programs and strategies to reduce the impact of disrespect, implicit bias and inequities that affect the care of pregnant persons.

High-fidelity simulation’s impact on clinical reasoning and patient safety: a scoping review.

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El Hussein MT, Hirst SP. J Nurs Reg. 2023;13:54-65.

Simulation-based training allows learners to learn and practice technical and non-technical skills in a low-risk environment. This review examines the effect of high-fidelity simulation (HFS) on clinical reasoning in nursing students. Results suggest HFS does improve clinical reasoning, but the included studies typically did not directly link improved clinical reasoning to improved patient safety.

Reducing hospital harm: establishing a command centre to foster situational awareness.

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Patient Safety Innovation March 29, 2023

Situational awareness during complex care events, such as clinical deterioration, medication administration, or the admission process, is an important component of teamwork and high reliability.

Demonstrating the value of a standardized cognitive assessment tool through the use of interprofessional rapid safety rounds.

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Patient Safety Innovation March 29, 2023

Cognitively impaired patients may be at increased risk of adverse events, such as falls, and assessment of cognitive status and implementation of appropriate supports is needed to improve their safety.

Pilot implementation of a health equity checklist to improve the identification of equity-related adverse events.

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Patient Safety Innovation March 29, 2023

Minoritized patients continue to experience disproportionately high rates of maternal morbidity and mortality. This hospital developed a health-equity checklist to identify if bias and/or social determinants of health played a role in preventable adverse events.

In Conversation with Christie Allen about Maternal Safety and Perinatal Mental Health

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Perspective on Safety March 28, 2023

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

"Are we there yet?" Ten persistent hazards and inefficiencies with the use of medication administration technology from the perspective of practicing nurses.

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Taft T, Rudd EA, Thraen I, et al. J Am Med Inform Assoc. 2023;Epub Mar 8.

Medication administration errors are major threats to patient safety. This qualitative study with 32 nurses from two US health system explored medication administration hazards and inefficiencies. Participants identified ten persistent safety hazards and inefficiencies, including issues with communication between safety monitoring systems and nurses, alert fatigue, and an overreliance on medication administration technology. These findings highlight the importance of developing medication administration technology in collaboration with frontline nurses who are tasked with medication administration.

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

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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.

Few hospitals are willing to bear the cost of providing psychiatric care for kids.

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Schorsch K, Karp S. WBEZ Chicago. March 9, 2023.

Pediatric mental health is a patient safety concern. This news story outlines the challenges to available services to address this need, tactics to keep young patients from harming themselves or others, and system-level approaches to improvement.

Closed-loop communication in interprofessional emergency teams: a cross-sectional observation study on the use of closed-loop communication among anesthesia personnel.

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Gjøvikli K, Valeberg BT. J Patient Saf. 2023;19:93-98.

Closed-loop communication prevents confusion and ensures the healthcare team is operating under a shared mental model. In order to investigate closed-loop communication in real-life care (as opposed to simulations), researchers observed 60 interprofessional teams, including 120 anesthesia personnel. The number of callouts, check-backs, and confirmations were analyzed, revealing only 45% of callouts resulted in closed-loop communication.

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