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 526 Results

Problems and paradoxes of reliability and resilience in organizational networks.

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Schulman PR. Safety Sci. 2023;167:106279.

Organizational resilience and high reliability principles take a proactive approach to ensuring patient safety. Using a safety science perspective, this article highlights key features of organizational and network reliability and resilience and the challenges in applying these features to complex systems.

Global Knowledge Sharing Platform for Patient Safety.

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World Health Organization.

The sharing of best practices is a key component of enabling successful strategy implementation in support of patient safety plans and goals. This website will capture, organize, and share experiences worldwide to support knowledge sharing and community building to reduce World Patient Safety Day targeted challenges.

Wake-up call: night shifts adversely affect nurse health and retention, patient and public safety, and costs.

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Imes CC, Tucker SJ, Trinkoff AM, et al. Nurs Adm Q. 2023;47:E38-E53.

Extended and overnight shifts are associated with higher adverse event rates and burnout. This mini review summarizes the impact of overnight shifts on nurses' health, patient and public safety, and organizational costs (e.g., those related to nurse turnover). Organizational strategies to promote nurses' health and reduce errors are also summarized, ranging from low-cost measures such as breaks for physical activity during the shift to high-cost measures such as referral to sleep specialists or paid transportation home.

Enhancing patient safety: a national standard for cyber resiliency in healthcare.

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Samuelson-Kiraly C, Mitchell JI, Kingston D, et al. Healthc Manage Forum. 2023;Epub Aug 30.

The threat of cybersecurity risks to patient safety is receiving increasing attention. This article describes the development of a new standard to support cyber resiliency in Canada’s healthcare system. The guidance addresses key areas of concern (e.g., organizational risk management, technology considerations, contingency planning), provides suggested roles and responsibilities for an organizational cybersecurity team, and emphasizes the importance of cyber incident response planning.

Making Healthcare Safer IV: A Continuous Updating of Patient Safety Harms and Practices.

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Rockville, MD: Agency for Healthcare Research and Quality: September 2023.

Patient safety progress is dynamic, consistently producing evidence for application to generate improvements. This report is the fourth in a series funded by the Agency for Healthcare Research and Quality to track a prioritized set of emerging and existing safety approaches to confirm their value and effectiveness. This report will be compiled as new conclusions are formulated. Each review will be posted to the collection as they are completed. The first three Making Healthcare Safer reports, published in 2001, 2013, and 2020, have each served as a consolidated evidence source for clinicians, health system leadership, researchers, and government agencies. Chapter protocols and the results of an examination of harms associated with video-based telehealth are now available.

In search of an international multidimensional action plan for second victim support: a narrative review.

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Seys D, Panella M, Russotto S, et al. BMC Health Serv Res. 2023;23:816.

Clinicians who are involved in a patient safety incident can experience psychological harm. This literature review of 104 studies identified five levels of support that can be provided to healthcare workers after a patient safety incident – (1) prevention, (2) self-care of individuals and/or teams, (3) support by peers and triage, (4) structured professional support, and (5) structured clinical support.

Harm Caused by Delays in Transferring Patients to the Right Place of Care.

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

Handoffs between prehospital emergency medical services (EMS) providers and hospital emergency departments (EDs) can be suboptimal, which increases patient harm potential. This report examines National Health Service discharge delays. It suggests a systemic approach is needed to address flow and capacity factors that contribute to ineffective and unsafe interfacility discharge and transfer.

Hiding in plain sight: inconvenient facts for patient safety in non-24/7 theatre on-site staffed obstetric units.

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McGurgan P. Aust N Z J Obstet Gynaecol. 2023;63:606-611.

Individual-, team-, and systems-based factors can affect safety during childbirth. This article discusses several patient safety threats that can hinder the safety of vaginal birth after cesarean (VAC) deliveries in high population density areas, including staffing and resource limitations, cultural and human factors, and patient communication.

When the lights go down in the delivery room: lessons from a ransomware attack.

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Gabbay‐Benziv R, Ben‐Natan M, Roguin A, et al. Int J Gynaecol Obstet. 2023;162:562-568.

Cyberattacks on healthcare systems are a rare but serious threat to public and patient safety. This article describes one obstetric department's experience with a weeklong cyberattack. Nearly every aspect of clinical care and monitoring was impacted, particularly loss of historical health record and electronic fetal heartrate monitoring. Adaptations to these and other affected services are detailed.

Beyond the Pandemic: Creating Total Systems Safety

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Perspective on Safety August 30, 2023

This piece focuses on the importance of patient safety following the end of the public health emergency and how organizations can move beyond the pandemic.

In Conversation with Patricia McGaffigan about Beyond the Pandemic: Creating Total Systems Safety

This piece focuses on the importance of patient safety following the end of the public health emergency and how organizations can move beyond the pandemic.

The e-Autopsy/e-Biopsy: A Systematic Chart Review to Increase Safety and Diagnostic Accuracy Innovation

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Patient Safety Innovation August 30, 2023

Addressing diagnostic errors to improve outcomes and patient safety has long been a problem in the US healthcare system.¹ Many methods of reducing diagnostic error focus on individual factors and single cases, instead of focusing on the contribution of system factors or looking at diagnostic errors across a disease or clinical condition. Instead of addressing individual cases, KP sought to improve the disease diagnosis process and systems. The goal was to address the systemic root cause issues in systems that lead to diagnostic errors.

Virtual Nursing: Improving Patient Care and Meeting Workforce Challenges

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Perspective on Safety August 30, 2023

This piece discusses virtual nursing, an approach to care that incorporates an advanced practice nurse into hospital-based patient care through telehealth. Virtual nursing increases patient safety and may enable expert nurses to continue to meet patient needs in future staffing shortages.

In Conversation with Kathleen Sanford and Sue Schuelke about Virtual Nursing

Editor’s note: Kathleen Sanford is the chief nursing officer and an executive vice president at CommonSpirit. Sue Schuelke is an assistant professor at the College of Nursing–Lincoln Division, University of Nebraska Medical Center. They have pioneered and tested a new model of nursing care that utilizes technology to add experienced expert nurses to care teams, called Virtual Nursing.

Drug shortages.

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Aronson JK, Heneghan C, Ferner RE. Br J Clin Pharmacol. Epub 2023 Jul 16.

Addressing drug shortages is a patient safety priority. Part One of this review summarizes existing definitions for drug shortages and the harms that can occur due to drug shortages (e.g., medication errors, treatment delays, undertreatment). Part Two discusses trends in drug shortages, the causes of drug shortages, and potential solutions.

Mind the power gap: how hierarchical leadership in healthcare is a risk to patient safety.

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Kanaris C. J Child Health Care. 2023;27:319-322.

Hierarchy as an organizational or team structure is known to affect patient safety. This editorial examines the impact a strict chain of command can have on communication and awareness-raising actions in the care environment. The author illustrates how a staff’s ability to contribute to care goals and raise concerns is enhanced when all are respected as having valuable insights without deference to role or education level.

Clinicians' insights on emergency department boarding: an explanatory mixed methods study evaluating patient care and clinician well-being.

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Loke DE, Green KA, Wessling EG, et al. Jt Comm J Qual Patient Saf. 2023;Epub Jul 2.

Quantitative studies have demonstrated that emergency department (ED) overcrowding and patient boarding contribute to adverse events. This study includes both qualitative and quantitative methods to understand how ED clinicians view the impact of boarding on their own well-being as well as patient safety. Key themes include clinician dissatisfaction and burnout, and high rates of verbal and physical abuse from boarding patients. Possible solutions included improved standardization of care, proactive planning, and culture change hospital-wide.

Sentinel Event Alert 67: Preserving Patient Safety After a Cyberattack.

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Jt Comm J Qual Patient Saf. 2023;Epub Aug 15.

Cyberattacks and technology disruptions are increasing as a threat to patient safety. This alert identifies risks linked to cyberattacks. The authors discuss how organizations might be proactive in order to prevent the potential for data breaches and reduce their impact on care delivery and processes should cyberattacks occur.

Nearly all hospital pharmacists say drug shortages are negatively impacting care; a third say impacts are ‘critical.’

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McPhillips D. CNN. August 10, 2023.

Drug shortages present clinicians and patients with numerous challenges. This news story discusses the extensive presence of medication shortages through the experience of health system pharmacists. It quantifies the impacts of drug shortages on effective care as they contribute to the delay, cancelation, or rationing of needed treatments.

Handling injectable medications in anaesthesia: Guidelines from the Association of Anaesthetists.

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Kinsella SM, Boaden B, El‐Ghazali S, et al. Anaesthesia. 2023;78:1285-1294.

Anesthesia provision is a high-risk practice. This guidance provides practical steps to ensure perioperative medication delivery is as safe as possible. This material recommends approaches for both clinicians and organizations to enable collaborative safety efforts in anesthesia, including prefilled syringes, standardization, and adherence to safe labeling practices.

Value assessment of deprescribing interventions: suggestions for improvement.

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Hung A, Wang J, Moriarty F, et al. J Am Geriatr Soc. 2023;71:2023-2027.

Deprescribing is used to reduce the risk of adverse drug events resulting from polypharmacy among older adults. This article outlines several recommendations for improved cost-effectiveness analyses of deprescribing interventions to support decision makers.

Supporting carers to improve patient safety and maintain their well-being in transitions from mental health hospitals to the community: a prioritisation nominal group technique.

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McMullen S, Panagioti M, Planner C, et al. Health Expect. 2023;26:2064-2074.

Caregivers and family members offer a unique perspective on patient safety. In this study, patient and caregiver stakeholders outlined the safety threats affecting patients discharged from mental health services and the well-being of caregivers as well as potential solutions. Participants highlighted approaches to improve caregiver involvement, patient and caregiver wellness and education, and the policy and system environments.

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