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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 498 Results

Boston, MA; Betsy Lehman Center; April 2023.

Well-told stories can motivate change. This video translates the experience of Massachusetts patients and family members with medical error for a broad audience. Clinicians also participate and share perspectives on problems in care systems that contribute to patient harm.
Passini L, Le Bouedec S, Dassieu G, et al. BMJ Qual Saf. 2023;Epub Mar 14.
Medical errors in the neonatal intensive care unit (NICU) are common and can result in significant patient harm. This prospective observational study conducted at 10 NICUs in France found that approximately 41% of the 1,822 errors (among 1,019 patients) were disclosed to the patient’s parents. Providers cited parental absence (i.e., the error occurred overnight) and perceived lack of serious consequences for the infant as the most frequent reason for non-disclosure.
Leapfrog Group
Drawing from data reported by the Leapfrog Hospital Survey, the Agency for Healthcare Research and Quality (AHRQ), the Centers for Disease Control and Prevention (CDC), and the Centers for Medicare and Medicaid Services (CMS), this website provides grades for hospitals in the United States based on their safety. The Spring 2023 hospital safety grade results, documenting the impact of COVID-19 on patient satisfaction and healthcare associated infection, are available. 
Adams M, Hartley J, Sanford N, et al. BMC Health Serv Res. 2023;23:285.
Patients and families expect full, timely disclosure after incidents. This realist synthesis examines research on patient disclosure to inform what is required to strengthen disclosure in maternity care. Five key themes were identified, including meaningful acknowledgment of harm and opportunities for patients and families to be involved in the follow-up.
Friedson AI, Humphreys A, LeCraw F, et al. JAMA Netw Open. 2023;6:e232302.
Disclosure of adverse events to patients and families is an important component of safety culture. AHRQ's Communication and Optimal Resolution (CANDOR) program provides tools to guide the disclosure process as well as peer support for healthcare providers (HCP) involved in the adverse event. This study aimed to identify associations with CANDOR implementation and HCP job satisfaction. Results indicate implementation of CANDOR increased some measures of HCP job satisfaction and trust in leadership, a novel finding not previously reported.
Schrimpff C, Link E, Fisse T, et al. Patient Educ Couns. 2023;110:107675.
Trust between patients and providers is essential to safe, effective healthcare. This survey of German patients undergoing implant surgeries (e.g., hip and knee replacements, dental implants, cochlear implants) found that adverse events negatively impact patient trust in their physicians, but effective patient-provider communication can mitigate the impacts.
Schnock KO, Garber A, Fraser H, et al. Jt Comm J Qual Patient Saf. 2023;49:89-97.
Reducing diagnostic errors is a primary patient safety concern. This qualitative study based on interviews with 17 providers and two focus group with seven patient advisors found broad agreement that diagnostic errors pose a significant threat to patient safety, as participants had difficulty defining and describing, and correctly identifying. the frequency of diagnostic errors in acute care settings. Participants cited issues such as communication failures, diagnostic uncertainty, and cognitive load as the primary factors contributing to diagnostic errors.

Järvinen TLN, Rickert J, Lee MJ, et al. Clin Orthop Relat Res. 2013-2023.

This quarterly commentary explores a wide range of subjects associated with patient safety, such as the impact of disruptive behavior on teams, the value of apologies, and safety challenges due to COVID-19. Older materials are available online for free.

Collaborative for Accountability and Improvement Policy Committee. Seattle, WA: University of Washington; 2022

Communication and resolution programs (CRP) show promise for improving patient and clinician communication after a harmful preventable adverse event. This tool provides a framework for organizational messaging on CRPs for patients and families.
Gillissen A, Kochanek T, Zupanic M, et al. Diagnosis (Berl). 2023;10:110-120.
Medical students do not always feel competent when it comes to patient safety concepts. In this study of German medical students, most understood the importance of patient safety, though few could identify concrete patient safety topics, such as near miss events or conditions that contribute to errors. Incorporating patient safety formally into medical education could improve students’ competence in these concepts.
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.
Fleming EA. JAMA. 2022;328:1297-1298.
Honest apology is known to support healing from medical error for clinicians, patients, and families. This essay shares the experience of one physician who missed signs of a heart attack, mislabeling the condition as fatigue, who then apologized for the mistake. The author highlights how openness about the error was crucial in the continuation of the care relationship.
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.

Davies JM, Steinke C, Flemons WW. New York, NY: Productivity Press; 2022. ISBN: 9781032028132.

Look-alike packaging can contribute to patient harm. This book examines how a mix up involving potassium chloride resulted in the deaths of two patients. The Canadian organization involved applied Reason’s strategies to work past blame to examine the events and consider how just culture can be entrenched organization-wide to improve safety for patients, families, and those who care for them.
Lin JS, Olutoye OO, Samora JB. J Pediatr Surg. 2023;58:496-502.
Clinicians involved in adverse events may experience feelings of guilt, shame, and inadequacy; this is referred to as “second victim” phenomenon. In this study of pediatric surgeons and surgical trainees, 84% experienced a poor patient outcome. Responses to the adverse event varied by level of experience (e.g., resident, attending), gender, and age.
Ramsey L, McHugh SK, Simms-Ellis R, et al. J Patient Saf. 2022;18:e1203-e1210.
Patients and families can contribute unique insights into medical errors. This qualitative evidence review concluded that patients and families value involvement in patient safety incident investigations but highlight the importance of addressing the emotional aspects of care (e.g., timely apology, prioritizing trust and transparency). Healthcare staff perceived patient and family involvement in investigations to be important, but cited several barriers (e.g., staff turnover, fears of litigation) to effective investigations.
Olazo K, Wang K, Sierra M, et al. Jt Comm J Qual Patient Saf. 2022;48:539-548.
Patients and families prefer to be told if they experience a medical error. Given that marginalized patients experience medical errors at higher rates, it is important to understand their unique perspectives and preferences towards error disclosure. This systematic review identified 6 studies focused on error disclosure in one of three marginalized populations (older adults, low education attainment, racial and/or ethnic minority).
de Loizaga SR, Clarke-Myers K, R Khoury P, et al. J Patient Exp. 2022;9:237437352211026.
Parents have reported the importance of being involved in discussions with clinicians following adverse events involving their children. This study asked parents and physicians about their perspectives on inclusion of parents in morbidity and mortality (M&M) reviews. Similar to earlier studies, parents wished to be involved, while physicians were concerned that parent involvement would draw attention away from the overall purpose (e.g., quality improvement) of M&M conferences.
McQueen JM, Gibson KR, Manson M, et al. BMJ Open. 2022;12:e060158.
Patients and families are important partners in improving patient safety. This qualitative study explored the experiences of patients and family members involved in adverse event reviews. The authors identified four themes (communication, trauma, learning and litigation) and outline eight key recommendations to address these themes by involving patients and families in adverse event reviews.