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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 424 Results
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.
Van der Voorden M, Ahaus K, Franx A. BMJ Open. 2023;13:e063175.
Patient engagement in healthcare is widely encouraged, but findings from some studies suggest that patient participation can have negative effects. This qualitative study with 16 patients and obstetric healthcare professionals examined the negative effects of patient participation in healthcare. Researchers identified four types of negative consequences from patient participation in safety – decreases in patient confidence, eroding of the patient-professional relationship, unwanted increases in patient responsibility, and excess time spent by professionals on the patient.
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.
Heesen M, Steuer C, Wiedemeier P, et al. J Patient Saf. 2022;18:e1226-e1230.
Anesthesia medications prepared in the operating room are vulnerable to errors at all stages of medication administration, including preparation and dilution. In this study, anesthesiologists were asked to prepare the mixture of three drugs used for spinal anesthesia for cesarean section. Results show deviation from the expected concentration and variability between providers. The authors recommend all medications be prepared in the hospital pharmacy or purchased pre-mixed from the manufacturer to prevent these errors. 
Hailu EM, Maddali SR, Snowden JM, et al. Health Place. 2022;78:102923.
Racial and ethnic health disparities are receiving increased attention, and yet structural racism continues to negatively impact communities of color. This review identified only six papers studying the impact of structural racism on severe maternal morbidity (SMM). Despite heterogeneity in measures and outcomes, the studies all demonstrated a link between structural racism and SMM; additional research is required.
Byrd TE, Ingram LA, Okpara N. Womens Health (Lond). 2022;18:174550572211338.
Maternal near misses are associated with lower quality of life and poorer outcomes for the pregnant person and their family. In this study, 12 Black women who experienced a maternal near miss describe major contributors. They list communication problems, such as not being believed, their relationship with their provider, and provider discrimination as major contributors.

Eldeib D. ProPublica. November 13, 2022.

Pregnancy is recognized as a high-risk condition for both mother and infant. This news story examines the potential for stillbirth and its preventability. Lack of respect for the concerns of mothers, inadequate attention to research, and poor patient education are discussed as contributors to stillbirth.

Kirkup B. Department of Health and Social Care. London, England: Crown Copyright; 2022.  ISBN: 9781528636759.

Maternity care is beset with challenges that reduce safety. This analysis provided insights into improving maternity care in the British National Health Service (NHS) focusing on the need for identification of inadequate performance, enhanced sympathetic care, common purpose in teams, honest response to difficulties and effective outcome measurement.
Kawsar M, Linander I. Sex Reprod Healthc. 2022;34:100786.
Trans and gender-nonconforming (TGNC) people may delay or avoid seeking healthcare due to experiences with biased or uninformed providers. This study focuses specifically on obstetric and gynecological care providers who provide care to TGNC people. Participants described challenges at the clinic level (e.g., needing at least one knowledgeable and interested clinician) and administrative level (e.g., trans men who have a cervix do not get automatic reminders for PAP tests) that can prevent TGNC people from receiving equitable care.
Barrow E, Lear RA, Morbi A, et al. BMJ Qual Saf. 2022;Epub Oct 5.
Patient and family engagement in safety is a priority for the UK’s National Health Service. This study asked patients in three hospital wards (geriatrics, elective surgery, maternity) how they conceptualize patient safety. Responses described what made them “feel safe” in their experiences with the organization, staff, the patients themselves, and family/carers.
Curated Libraries
October 10, 2022
Selected PSNet materials for a general safety audience focusing on improvements in the diagnostic process and the strategies that support them to prevent diagnostic errors from harming patients.
Brown TH, Homan PA. Health Serv Res. 2022;57:443-447.
Structural racism, from race-adjusted algorithms to biased machine learning, contributes to and exacerbates health inequities. This commentary calls for developing valid measures of structural racism and a publicly available data infrastructure for researchers. A related study examined the relationship between structural racism and birth outcomes between Black and white patients in Minnesota.
Ghaith S, Campbell RL, Pollock JR, et al. Healthcare (Basel). 2022;10:1328.
Obstetric and gynecologic (OB/GYN) physicians are frequently involved in malpractice lawsuits, some of which result in catastrophic payouts. This study categorized malpractice claims involving OB/GYN trainees (students, residents, and fellows) between 1986 and 2020. Cases are categorized by type of injury, patient outcome, category of error, outcome of lawsuit, and amount of settlement.

Farnborough, UK: Healthcare Safety Investigation Branch; 2022. HSIB Report no. NI-005831

This report summarizes the work of an independent office that examines maternity care safety lapses in the United Kingdom. It discusses the number of investigations done, criteria for investigation selection and primary improvement themes drawn from the review of 706 investigations in the period covered which include clinical assessment and oversight, care escalation, and fetal monitoring. The report outlines the goal to establish a maternity review effort as an independent entity in 2023.
Taylor DJ, Goodwin D. J Med Ethics. 2022;48:672-677.
Normalization of deviance describes a situation where individuals, teams or organizations accept a lower standard of performance until that lower standard becomes the “norm” and can threaten patient safety. This article describes five serious medical errors in obstetrics and highlights how normalization of deviance contributed to each event.

National Institutes of Health.  August 11, 2022. RFA-HD-23-035.

Maternity care is increasingly being recognized as vulnerable to implicit biases and social inequities. This funding announcement aims to support initiatives that promote equity as a primary component of efforts to study preventable maternal harm in a variety of disadvantaged and ethnic populations. The application process is now closed.

Feibel C. Consider This. National Public Radio. August 3, 2022. 

Maternal complications risk the health of both mothers and babies, and a variety of circumstances create challenges to this complex care process. This article describes delays in care for a pregnant patient due to legal and policy concerns that threatened the life of the mother.