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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 1194 Results
Patient Safety Innovation July 31, 2023

Concern over patient safety issues associated with inadequate tracking of test results has grown over the last decade, as it can lead to delays in the recognition of abnormal test results and the absence of a tracking system to ensure short-term patient follow-up.1,2 Missed abnormal tests and the lack of necessary clinical follow-up can lead to a late diagnosis.

Shin P, Desai V, Conte AH, et al. Perm J. 2023;27:160-168.
Burnout among healthcare workers is widespread and can threaten patient safety. This article summarizes the individual, organizational, and culture factors contributing to perioperative physician burnout, how burnout impacts surgical patient care, and strategies to mitigate perioperative physician burnout.
Schrøder K, Assing Hvidt E. Int J Environ Res Public Health. 2023;20:5749.
Healthcare providers may experience emotional distress after involvement in an adverse or traumatic event. This qualitative study with 198 healthcare professionals identified common emotions experienced after adverse events as well as the types of support needed after involvement in an adverse event. These findings can contribute to the development and refinement of support programs for healthcare workers after adverse events.
AHA Team Training. September 7 - November 2, 2023.
The TeamSTEPPS program was developed to support effective communication and teamwork in health care. This online series will prepare participants to guide their organizations through implementation of the TeamSTEPPS program. It is designed for individuals that are new to TeamSTEPPS processes. 
Wolf MS, Smith K, Basu M, et al. J Pediatr Intensive Care. 2023;12:125-130.
Preventable harm continues to occur in high-risk care environments such as the pediatric intensive care unit (ICU). In this survey of 266 clinicians within a large pediatric healthcare system, 42% reported experiencing psychological distress after an adverse event, 22% reported absenteeism and 23% reported considering leaving the ICU. After involvement in an adverse event, respondents said that they would prefer peer support and the ability to step away from the unit to recover.
Patient Safety Innovation May 31, 2023

Seeking a sustainable process to enhance their hospitals’ response to sepsis, a multidisciplinary team at WellSpan Health oversaw the development and implementation of a system that uses customized electronic health record (EHR) alert settings and a team of remote nurses to help frontline staff identify and respond to patients showing signs of sepsis. When the remote nurses, or Central Alerts Team (CAT), receive an alert, they assess the patient’s information and collaborate with the clinical care team to recommend a response.

May 4, 2023
The implementation of effective patient safety initiatives is challenging due to the complexity of the health care environment. This curated library shares resources summarizing overarching ideas and strategies that can aid in successful program execution, establishment, and sustainability.

Gerteis J, Booker C, Brach C, et al. Rockville, MD:  Agency for Healthcare Research and Quality; February 2023. AHRQ Publication No. 23-0025.

Burnout reduction in primary care is critical to patient safety. This resource is designed to help practices assess the causes of burnout in primary care and implement strategies to promote well-being. Suggested areas of focus include the reduction of documentation tasks, use of huddles and peer support.
Rockville MD: Agency for Healthcare Research and Quality; 2020.
Culture has been described as a key to establishing high reliability organizations. The National Quality Forum's Safe Practices for Healthcare and the Leapfrog Group both mandate hospitals to regularly assess their safety culture. This AHRQ Web site provides validated safety culture survey tools (Hospital, Medical Office, Nursing Home, Community Pharmacy, Ambulatory Surgery Center), user guides health care organizations can use to implement the surveys and a bibliography of articles discussing the use of SOPS in the field. Organizations can also use the AHRQ database to compare their Surveys on Patient Safety Culture™ (SOPS®) results. In addition, reports are available that summarize the benchmarking data across cohorts nationwide. An AHRQ WebM&M perspective discussed how to establish a safety culture.
Perspective on Safety April 26, 2023

Throughout 2022, AHRQ PSNet has shared research that elucidates the complex nature of misdiagnosis and diagnostic safety. This Year in Review explores recent work in diagnostic safety and ways that greater safety may be promoted using tools developed to improve diagnostic practices.

Throughout 2022, AHRQ PSNet has shared research that elucidates the complex nature of misdiagnosis and diagnostic safety. This Year in Review explores recent work in diagnostic safety and ways that greater safety may be promoted using tools developed to improve diagnostic practices.

Perspective on Safety April 26, 2023

This piece discusses surveillance monitoring of patients in low-acuity units of the hospital to prevent failure to rescue events, its difference from high-acuity continuous monitoring, and its potential applications in other settings.

This piece discusses surveillance monitoring of patients in low-acuity units of the hospital to prevent failure to rescue events, its difference from high-acuity continuous monitoring, and its potential applications in other settings.

Drs. Susan McGrath and George Blike discuss surveillance monitoring and its challenges and opportunities.

McIntosh MS, Garvan C, Kalynych CJ, et al. Jt Comm J Qual Patient Saf. 2023;49:207-212.
Physician burnout is widespread, can affect physician wellness, and threaten patient safety. This article describes the development of the Center for Healthy Minds and Practice (CHaMP) program at the University of Florida College of Medicine-Jacksonville, which aims to improve crisis response, build peer support, and remove barriers to accessing mental health care for medical students, clinicians, staff, and other healthcare workers.
Benishek LE, Kachalia A, Daugherty Biddison L. JAMA. 2023;329:1149-1150.
The quality and culture of the health care work environment is known to affect care delivery. This commentary discusses human-centered and participatory design approaches as avenues for developing improvements in clinician well-being that will enhance safety for staff, providers, and patients.

Dabekaussen K, Scheepers RA, Heineman E, et al. PLoS One. 2023;18(1):e0280444.

Disruptive and unprofessional behavior has been linked to adverse events and staff burnout. This study describes the frequency and types of unprofessional behavior among health care professionals and identifies those most likely to exhibit unprofessional behavior and who is the likely target. Nearly two-thirds of respondents experienced unprofessional behavior at least monthly, most frequently from those outside their department.
Abrams R, Conolly A, Rowland E, et al. J Adv Nurs. 2023;79:2189-2199.
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.
Huff NR, Liu G, Chimowitz H, et al. Int J Nurs Stud Adv. 2022;5:100111.
Negative emotions can adversely impact perception of both patient safety and personal risks. In this study, emergency nurses were surveyed about their emotions (e.g., afraid, calm), emotional suppression and reappraisal behaviors, and perceived risk of personal and patient safety during the COVID-19 pandemic. Nurses reported feeling both positive and negative emotions, but only negative emotions were significantly associated with greater perception of risk.
Greig PR, Zolger D, Onwochei DN, et al. Anaesthesia. 2023;78:343-355.
Cognitive aids, such as checklists and decision aids, can reduce omissions in care and improve patient safety. This systematic review including 13 randomized trials found that cognitive aids in clinical emergencies reduced the incidence of missed care steps (from 43% to 11%) and medical errors, and improved teamwork, non-technical, and conflict resolution scores.
Aubin DL, Soprovich A, Diaz Carvallo F, et al. BMJ Open Qual. 2022;11:e002004.
Healthcare workers (HCW) and patients can experience negative psychological impacts following medical error; the negative impact can be compounded when workers and patients are prevented from processing the error. This study explored interactions between patients/families and HCWs following a medical error, highlighting barriers to communication, as well as the need for training and peer support for HCWs. Importantly, HCW and patients/families expressed feeling empathy towards the other and stressed that open communication can lead to healing for some.
Leitman IM, Muller D, Miller S, et al. JAMA Netw Open. 2022;5:e2244661.
The effectiveness of incident reporting systems is hindered by underreporting. This cohort study describes the characteristics of incident reports submitted by trainees in a large academic medical center. From October 2019 through December 2021, trainees submitted nearly 200 incident reports, primarily describing unprofessional interactions. Findings suggest that awareness and support for the online incident reporting system among trainees was high.
Kim S, Lynn MR, Baernholdt MB, et al. J Nurs Care Qual. 2022;38:11-18.
In response to concerns about workplace violence (WPV) directed at healthcare workers in the US, the Joint Commission issued a Sentinel Event Alert and recommendations to increase organizational awareness of this risk. This study evaluated the effect of one of those recommendations, a WPV-reporting culture, on nurses’ burnout and patient safety. As anticipated, WPV increased nurse burnout, but unexpectedly, a strong WPV-reporting culture also increased the negative effect of WPV on burnout.