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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 219 Results
Sutton E, Booth L, Ibrahim M, et al. Qual Health Res. 2022;32:2078-2089.
Patient engagement and encouragement to speak up about their care can promote patient safety. This qualitative study explored patients’ psychosocial experiences after surviving abdominal surgery complications. Findings highlight an overarching theme of vulnerability and how power imbalances between patients and healthcare professionals can influence speaking up behaviors.
Pedrosa Carrasco AJ, Bezmenov A, Sibelius U, et al. Am J Hosp Palliat Care. 2022:104990912211400.
Patients with medical complexities who are receiving palliative care may be at increased risk for patient safety events. This cross-sectional survey found that patient safety concerns were common among patients receiving specialist community palliative care in Germany. Patients reported that physical disability, physical and psychological symptoms, and side effects or complications from medication therapy were the most common causes of impaired safety, as well as the COVID-19 pandemic.
Groves PS, Bunch JL, Hanrahan KM, et al. Clin Nurs Res. 2023;32:105-114.
Patients can provide a unique perspective on safety concerns but may hesitate to speak up. This study was conducted with 19 recently discharged patients or their family members to understand safety or quality concerns they experienced during their stay and whether they voiced the concern to their care team. The paper presents types of concerns and, if parents did not have concerns, what made them feel safe, as well as barriers and facilitators to speaking up.
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.
Reader TW. J Risk Res. 2022;25:807-824.
Feedback from patients and other stakeholders can illuminate serious patient safety concerns. This qualitative study analyzed stakeholder feedback about patient safety risks as well as how organizations responded to stakeholder communication and discusses ways in which organizational risk management teams can leverage stakeholder feedback. Findings suggest that stakeholder communications have typically focused on safety issues such as medication errors, but that poor safety culture meant that concerns were often not acted upon.
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.

Millenson M. Forbes. September 16, 2022.

Unnecessary medication infusions indicate weaknesses in medication service processes. While no harm was noted in the case discussed, the actions by the patient’s family to initiate an examination of the incident were rebuffed, patient disrespect was demonstrated, a near miss incident report was absent, and data omissions took place. The piece discusses how these detractors from safety were all present at the hospital involved.
Keller C. Health Aff (Millwood). 2022;41:1353-1356.
Communication failures due to hierarchy and silos create opportunities for adverse medication and treatment events. This narrative essay discusses gaps in care coordination that contributed to anticoagulant medication errors. The author outlines areas for improvement such as assignment of accountability for error and commitment to the learning health system as avenues for improvement.
Gillespie A, Reader TW. Risk Anal. 2022;Epub Aug 9.
Patients are uniquely situated to identify safety risks that may be missed or not reported by healthcare providers. This study used automated language analysis to analyze more than 140,000 reports submitted by patients and families to an online reporting system in the UK. Despite limitations, online patient feedback can serve as an additional source of potential safety risks.
Occelli P, Mougeot F, Robelet M, et al. J Patient Saf. 2022;18:415-420.
Understanding patient experience can provide key insights about safety culture. This qualitative study of 80 adult patients concluded that patients’ perspectives of surgical safety are closely tied to the degree of trust they have in their surgeons; this trust is based on the patient’s relationship with their surgeon, communication style, and the patient’s experience during perioperative consultation.
Mercer AN, Mauskar S, Baird JD, et al. Pediatrics. 2022;150:e2021055098.
Children with serious medical conditions are vulnerable to medical errors. This prospective study examined safety reporting behaviors among parents of children with medical complexity and hospital staff caring for these patients in one tertiary children’s hospital. Findings indicate that parents frequently identify medical errors or quality issues, despite not being routinely advised on how to report safety concerns.
Hemmelgarn C, Hatlie MJ, Sheridan S, et al. J Patient Saf Risk Manage. 2022;27:56-58.
This commentary, authored by patients and families who have experienced medical errors, argues current patient safety efforts in the United States lack urgency and commitment, even as the World Health Organization is increasing its efforts. They call on policy makers and safety agencies to collaborate with the Patients for Patient Safety US organization to move improvement efforts forward.
Donnelly LF, Uhlhorn E, Bargmann-Losche J, et al. J Patient Exp. 2022;9:237437352211026.
Combining patient complaints and staff incident reports allows hospitals to better understand causes of patient harm. This children’s hospital designed a program to investigate serious experience events (SEE) modeled after their serious safety events (SSE) program. Through case studies, the authors describe how patient complaints were investigated to improve both patient experience and safety.
Khan A, Baird JD, Kelly MM, et al. Pediatrics. 2022;149:e2021053913.
Patient and family engagement in safety efforts is supported in research but patients and clinicians still experience barriers in providing and accepting feedback. In this study, parents and caregivers of medically complex children reported uncertainty about whether and to whom to report concerns. Other themes included misalignment of staff and parent expectations of care and staff and leadership buy-in on the value of parent engagement.
Morsø L, Birkeland S, Walløe S, et al. Jt Comm J Qual Patient Saf. 2022;48:271-279.
Patient complaints can provide insights into safety threats and system weaknesses. This study used the healthcare complaints analysis tool (HCAT) to identify and categorize safety problems in emergency care. Most problems arose during examination/diagnosis and frequently resulted in diagnostic errors or errors of omission.
Madden C, Lydon S, Murphy AW, et al. Fam Pract. 2022;39:1095-1102.
Patient complaints and patient-reported incidents can help identify safety issues. This study compared clinician perceptions and patients’ accounts regarding patient safety incidents and identified a significant difference in perceptions about incident severity. Patients’ accounts of incidents commonly described deficiencies related to communication, staff performance, compassion, and respect.
Cucchiaro SÉ, Princen F, Goreux JË, et al. Int J Qual Health Care. 2022;34:mzac014.
Patient satisfaction surveys, unexpected event reports and patient complaints can each be used to improve patient safety. This radiotherapy service combined the three sources to make improvements in safety and quality. Results highlighted areas of strength (e.g., physical healing, kindness) and areas to improve (e.g., scheduling, comfort). Involving the patient in this way could lead to improvements in quality and safety.
Bardach NS, Stotts JR, Fiore DM, et al. J Hosp Med. 2022;17:456-465.
Patients and families represent an often untapped resource in identifying errors and adverse events. Using a mobile health tool, pediatric patients and families were encouraged to report safety events that occurred during the child’s hospital stay. These reports were compared with incident reports (IRs) submitted to the internal incident reporting system. Of the 51 potential IR observations, only one had been submitted to the IR system. Notably, differences in the number of reported events varied by race, ethnicity, insurance status, and other marginalized groups, highlighting a need to explicitly engage these populations. 

Washington, DC: United States Government Accountability Office; November 30, 2021. Publication GAO-22-105142.

Patient complaints have the potential to be used for care improvement as they surface problems in health facilities. This report examined complaint response processes in Veterans Affairs nursing homes and found them lacking. Five recommendations submitted to drive improvement underscore the value of adherence to policy and the transfer of complaint experiences to leadership.

Norah Frye Centre for Disability Studies; Bristol, England.

People with a Learning Disability and autistic people (LeDeR) is a National Health Service-sponsored initiative that seeks to improve the care of learning disabled patients through examining what goes right and what goes wrong. The website includes a reporting function, patient-focused resources, and annual reports to distribute conclusions drawn from data analysis to inform improvements in the care of this patient population.