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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 779 Results
Pugh S, Chan F, Han S, et al. J Nurs Adm. 2023;53:292-298.
The COVID-19 pandemic dramatically impacted the delivery of nursing care. This retrospective analysis examined the impact of a bedside checklist and nursing-led intervention bundle (“Nursing Back to Basics” or NB2B bundle) among patients hospitalized with COVID-19 at one academic hospital in New York City. The NB2B bundle, implemented with a bedside checklist, included five evidence-based interventions. Between March and April 2020, the NB2B intervention showed a 12% reduction in mortality due to COVID-19 compared with usual care.

Massachusetts Protection and Advocacy. Boston, MA:  Disability Law Center; May 8, 2023.

Behavioral health patients present unique challenges in their care that can contribute to unintended harm. The analysis examines a delayed diagnosis, referral, and treatment of skin cancer that contributed to the death of a patient. Suggestions for improvement included conducting a root cause analysis to identify systemic problems, use of photography to track skin lesion progression, and implementation of a warm handoff process to improve staff communication.
Wiegand AA, Sheikh T, Zannath F, et al. BMJ Qual Saf. 2023;Epub May 10.
Sexual and gender minority (SGM) patients may experience poor quality of healthcare due to stigma and discrimination. This qualitative study explored diagnostic challenges and the impact of diagnostic errors among 20 participants identifying as sexual minorities and/or gender minorities. Participants attribute diagnostic error to provider-level and personal challenges and how diagnostic error worsened health outcomes and led to disengagement from healthcare. The authors of this article also summarize patient-proposed solutions to diagnostic error through the use of inclusive language, increasing education and training on SGM topics, and inclusion of more SGM individuals in healthcare.
Kepner S, Bingman C, Jones RM. Patient Saf. 2023;Epub Apr 28.
Healthcare-associated infections remain a patient safety issue at long-term care facilities. Based on incident data from the Pennsylvania Patient Safety Reporting System (PA-PSRS), this analysis found that healthcare-associated infections in long-term care settings increased by 12.5% between 2021 and 2022; over half of this increase is due to an increase in respiratory and gastrointestinal infections.
Cohen TN, Berdahl CT, Coleman BL, et al. J Nurs Care Qual. 2023;Epub May 9.
Institutional error and near-miss reporting helps identify systemic weaknesses and areas for improvement. COVID-19 presented a unique environment to study error reporting during organizationally stressful times. In this study, incident reports of medication errors or near misses during a COVID-19 surge were analyzed. Skill-based (e.g., forgetting to administer a dose) and communication errors were the most common medication safety events.

Bryant A. UpToDate. May 18, 2023.

Implicit bias is progressively being discussed as a detractor to safe health care by fostering racial and ethnic inequities. This review examines the history of health inequities at the patient, provider, health care system, and cultural levels in obstetric and gynecologic care. It shares actions documented in the evidence base for application in health care to reduce the impact of implicit bias, with an eye toward maternal care
Rainer T, Lim JK, He Y, et al. Hosp Pediatr. 2023;13:461-470.
Structural racism and implicit biases can affect clinical judgement and impede the delivery of effective mental health care. Based on a case of an adolescent Black girl navigating through the pediatric behavioral health system, this article discusses how structural racism and health disparities in behavioral health care contributed to misdiagnosis and poor care. The authors outline several actions at the structural, institutional, and interpersonal levels to address racism’s impact on pediatric mental and behavioral healthcare.

Freedman DH.  Newsweek Magazine. May 12, 2023.

The unintended consequences of reductions in access to prescription opioids can result in poor addiction care and ineffective pain management. This article discusses precursors to the system failure affecting these patients and treatment options that work given access and supply constraints.

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

Misattribution of child maltreatment injuries can be a serious misdiagnosis affecting families and patients. This report analyzes ten safety incident reports from across the British National Health Service to explore how non-accidental injury was missed. Themes identified as contributing to the problems include lack of information sharing, inconsistent guidance, and emergency department care demands.
Yackel EE, Knowles RS, Jones CM, et al. J Patient Saf. 2023;Epub May 1.
The COVID-19 pandemic dramatically changed healthcare delivery and exacerbated threats to patient safety. Using Veterans Health Administration (VHA) National Center for Patient Safety data, this retrospective study characterized patient safety events related to COVID-19 occurring between March 2020 and February 2021. Delays in care and exposure to COVID-19 were the most common events and confusion over procedures, missed care, and failure to identify COVID-positive patients before exposures were the most common contributing factors.
Royce CS, Morgan HK, Baecher-Lind L, et al. Am J Obstet Gynecol. 2023;228:369-381.
Racism and implicit biases can threaten the safety of care. The authors in this article outline how implicit bias can affect health professional trainees and impact patient care in obstetrics and gynecology, and outlines strategies to address implicit bias through bias awareness and management curricula, ensuring a supportive learning environment, and faculty development.

Covid Crisis Group. New York: Public Affairs; 2023. ISBN‏: ‎9781541703803.

The transfer of failure experiences to generate learning and improve service is a complicated responsibility. This book examines breakdowns in the US response to the COVID-19 epidemic to understand causes of the problems, in order to better prepare health care, government, and public health systems for future pandemics. It also discusses what successes were achieved and how to capitalize on those improvements.
Edwards SE, Class QA, Ford CE, et al. Am J Obstet Gynecol MFM. 2023;5:100927.
Racial bias negatively impacts maternal safety across all stages of pregnancy. This study used two clinical scenarios to assess obstetricians' likelihood to recommend cesarean section during labor at three decision points. All participants received the same scenarios with the only difference being the patient's race (i.e., Black or white). No significant racial biases were detected overall, but one subgroup (younger providers and those with less experience) opted for cesarean delivery more frequently for Black patients than white patients at one decision point.
de Arriba Fernández A, Sánchez Medina R, Dorta Hung ME, et al. J Patient Saf. 2023;19:249-250.
As more patients with COVID-19 were admitted to hospitals during the pandemic, concerns about healthcare-acquired COVID-19 and potential associated adverse events increased. In this retrospective study, 126 patients with hospital-acquired COVID-19 were moved to isolation or quarantine. Twenty-nine patients experienced one or more adverse events due to isolation or quarantine, including delayed transfer to other specialties and delayed diagnostic tests. Nosocomial COVID-19 infection was confirmed as cause of death in one patient, and a possible cause in 11 others.
Baffoe JO, Moczygemba LR, Brown CM. J Am Pharm Assoc (2003). 2023;63:518-528.
Minoritized and vulnerable people often experience delays in care due to systemic biases. This survey study examined the association between perceived discrimination at community pharmacies and foregoing or delaying picking up medications. Participants reported discrimination based on race, age, sexual orientation, ethnicity, income, and prescription insurance; those participants were more likely to delay picking up their medications. There was no association with discrimination and foregoing medications.
Njoku A, Evans M, Nimo-Sefah L, et al. Healthcare. 2023;11:438.
Maternal morbidity and mortality are disproportionately experienced by persons of color in the United States. The authors of this article present a socioecological model for understanding the individual, interpersonal, organizational, community, and societal factors contributing to Black maternal morbidity and mortality. The authors outline several recommendations for improving care, including workforce diversification, incorporating social determinants of health and health disparities into health professional education, and exploring the impact of structural racism on maternal health outcomes.  
Sands KE, Blanchard EJ, Fraker S, et al. JAMA Netw Open. 2023;6:e238059.
Changes in healthcare delivery due to the COVID-19 pandemic raised concerns about increases in healthcare-acquired infections (HAIs). This cross-sectional analysis of more than five million hospitalizations between 2020 and 2022 found that the incidence of HAIs was higher among patients hospitalized with COVID-19 compared to patients hospitalized without COVID-19.
Mills PD, Louis RP, Yackel E. J Healthc Qual. 2023;Epub Apr 11.
Changes in healthcare delivery due to the COVID-19 pandemic resulted in delays in care that can lead to patient harm. In this study using patient safety event data submitted to the VHA National Center of Patient Safety, researchers identified healthcare delays involving laboratory results, treatment and interventional procedures, and diagnosis.