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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 476 Results

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.
Patient Safety Innovation March 29, 2023

Medication reconciliation is a common strategy to improve patient safety but is complex and time consuming. Three academic medical centers developed and implemented a risk stratification tool so limited pharmacist resources could be allocated to patients with the highest likelihood of medication adverse events.

Brooks K, Landeg O, Kovats S, et al. BMJ Open. 2023;13:e068298.
National and organizational emergency response plans lay out policies and procedures to prepare for and respond to unexpected natural disasters and other public health emergencies. This study examines clinician and non-clinician perspectives on safety during the 2019 record-breaking heatwave in the United Kingdom. Clinicians reported not being aware of national heatwave preparedness and response plans, and several challenges were mentioned, including insufficient cooling equipment. 
Perspective on Safety March 21, 2023

Throughout 2022, the impact of system failures on healthcare workers was a recurrent theme of articles on AHRQ PSNet. This Year in Review explores these impacts and ways to support healthcare workers involved in a system failure.  

Patient Safety Innovation March 15, 2023

During a time of unprecedented patient volume and clinical uncertainty, a diverse team of health system administrators and clinicians within the University of Pennsylvania Health System quickly investigated, updated, and disseminated airway management protocols after several airway safety incidents occurred among COVID-19 patients who were mechanically ventilated. Based on this experience, the team created the I-READI framework as a guide for healthcare systems to prepare for and quickly respond to quality and safety crises.1

WebM&M Case March 15, 2023

A 71-year-old man presented to his physician with rectal bleeding and pain, which was attributed to radiation proctitis following therapy for adenocarcinoma of the prostate. He subsequently developed a potentially life-threatening complication of sepsis while awaiting follow up care for a spontaneous rectal perforation. The commentary addresses the importance of early identification and timely intervention in the event of treatment failure and the post-discharge follow-up programs to improve care coordination and communication during transitions of care.

Evans WR, Mullen DM, Burke-Smalley L. J Health Organ Manag. 2023;Epub Jan 24.
Nurses have reported experiencing horizontal abuse and bullying (e.g., bullying by other nurses) and perceive that workplace bullying results in errors. Using posts from the social media site Reddit, researchers sought to understand who perpetrates the abuse, types of abuse, perceived reasons, nurses’ responses, and location of abuse. Organizational strategies such as mindfulness, reshaping the culture, bystander interventions and explicit leadership support are suggested to prevent nurse co-worker abuse.
Gross TK, Lane NE, Timm NL, et al. Pediatrics. 2023;151:e2022060971-e2022060972.
Emergency room crowding is a persistent factor that degrades safety for patients of all ages. This collection provides background, best practices, and recommendations to reduce emergency department crowding and its negative impact on pediatric care. The publications examine factors that influence crowding and improvement at the input, departmental, and hospital/outpatient stages of emergency care.

ISMP Medication Safety Alert! Acute care edition. February 23, 2023;28(4):1-4; March 9, 2023:28(5):1-4.

Drug diversion can reduce patient safety and should be addressed at a system level to reduce its occurrence and impact. Part I of this two-part series examines ways in which drug diversion can affect care teams, and outlines what to watch for to flag its occurrence at the clinician, record keeping, and medication inventory levels. Part II shares tactics to minimize controlled substance diversion, and track, document and take action when it does occur.
Curated Libraries
March 8, 2023
Value as an element of patient safety is emerging as an approach to prioritize and evaluate improvement actions. This library highlights resources that explore the business case for cost effective, efficient and impactful efforts to reduce medical errors.
Benishek LE, Kachalia A, Daugherty Biddison L. JAMA. 2023;Epub Feb 23.
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.
Halligan D, Janes G, Conner M, et al. J Patient Saf. 2023;19:143-150.
Reducing low-value tests and treatments has been a focus of patient safety efforts, but less attention has been focused on low-value patient safety practices (PSP). This study describes the concept of “safety clutter” and understanding which PSP are of low-value, ineffective, and could be discontinued. Frequently cited PSP included paperwork, duplication, and intentional rounding.

Reed J. BBC. February 27, 2023.

Stressful and caustic work environments are known to compromise health care safety and teamwork. This news story discusses an ongoing investigation in the British National Health Service to examine factors in ambulance services that minimize its safety and effectiveness. Clinicians interviewed revealed serious problems with the work cultures.

Farnborough, UK: Healthcare Safety Investigation Branch; February 2023.

Patient misidentification in emergent situations can reduce the appropriateness of care delivery and safety. This report analyzes an incident where the healthcare team misidentified a patient (who had a do-not-resuscitate order) and withheld cardiopulmonary resuscitation (CPR) from the wrong patient. The lack of access to health information technology at the bedside, and reference to the patient’s wristband, were factors contributing to the patient’s death.

Washington, DC: VA Office of the Inspector General; February 2, 2023. Report no. 22-01363-52.

Gaps in care for psychologically vulnerable patients can result in harm to family members and self-harm. This report examines organizational failures in responding to staff and clinical leaders’ concerns regarding access, triage, and care continuity for mental health patients. Recommendations for improvement include same-day access to appropriate specialty care, medication management, and risk documentation.
Raff L, Moore C, Raff E. Hosp Pract (1995). 2023;51:29-34.
Language barriers can lead to diminished care and threaten patient safety. This retrospective study included patients with rapid response team (RRT) activation and compared disease severity and outcomes for patients whose primary language was Spanish versus English. Findings suggest that language barriers may contribute to delays in RRT activation and delays in care.
Kobeissi MM, Hickey JV. Jt Comm J Qual Patient Saf. 2023;49:213-222.
The COVID-19 pandemic led to the rapid expansion and adoption of telehealth. The authors of this article discuss how to leverage the increased use of telehealth and propose a new organizational telehealth program model to help organizations develop and sustain safe, equitable, and high-quality telehealth programs.

Infect Control Hosp Epidemiol. 2022-2023.

Health care–associated infections (HAIs) affect patients both during and after hospitalization. The use of patient safety methods as well as traditional infection control practices has resulted in significant successes in curbing HAIs such as central-line bloodstream infections. This set of practice guidelines will be developed and disseminated over the course of 2022-2023 to summarize preemptive actions and implementation strategies for prevention of HAIs.
Salmon PM, Coventon L, Read GJM. Safety Sci. 2022;156:105899.
Healthcare workers are at high risk of violence from patients, caregivers, and other healthcare workers. Researchers used three systems thinking methods (ActorMap, AcciMap, and PreventiMap) and stakeholder input to identify factors contributing to work-related violence incidents and interventions that can prevent or mitigate work-related violence.