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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 5145 Results
Perspective on Safety March 29, 2023

In the past several decades, technological advances have opened new possibilities for improving patient safety. Using technology to digitize healthcare processes has the potential to increase standardization and efficiency of clinical workflows and to reduce errors and cost across all healthcare settings.1 However, if technological approaches are designed or implemented poorly, the burden on clinicians can increase. For example, overburdened clinicians can experience alert fatigue and fail to respond to notifications. This can lead to more medical errors.

WebM&M Case March 29, 2023

An adult woman with a history of suicidal ideation was taking prescribed antidepressants, but later required admission to the hospital after overdosing on her prescribed medications. A consulting psychiatrist evaluated the patient but recommended sending her home on a benzodiazepine alone, under observation by her mother.

WebM&M Case March 29, 2023

This patient with recently diagnosed adenocarcinoma of the esophagus underwent esophagoscopy with endoscopic ultrasound, which was complicated by thoracic esophageal perforation. The perforation was endoscopically closed during the procedure. However, there was a lack of clear communication regarding the operator’s confidence in the success of endoscopic closure and their recommendations for the modality and timing of follow-up imaging, which ultimately led to significant delays in patient care.

Agbar F, Zhang S, Wu Y, et al. Nurse Educ Pract. 2023;67:103565.
Health systems seeking to improve patient safety culture (PSC) implement myriad of educational programs for their staff. This review identified 16 studies of PSC education programs that included before and after surveys or intervention and control groups. Results were generally positive, but repeated trainings may be needed to sustain the change. Additionally, based on the reporting using the AHRQ Hospital Survey of Patient Safety Culture (HSOPS), a culture of blame remained a pervasive problem despite improvements in other components of patient safety culture in many hospitals.
Barlow M, Watson B, Jones EW, et al. BMC Nurs. 2023;22:26.
Healthcare providers may decide to speak up or remain silent about patient safety concerns based on the expected response of the recipient. In this study, clinicians from multiple disciplines responded to two hypothetical speaking up scenarios to explore the impact of communication behavior and speaker characteristics (e.g., discipline, seniority, presence of others) on the recipient’s intended response. Each of the factors played a role in how the clinician received the message and how they would respond.
Sloane JF, Donkin C, Newell BR, et al. J Gen Intern Med. 2023;Epub Jan 25.
Interruptions during diagnostic decision-making and clinical tasks can adversely impact patient care. This article reviews empirically-tested strategies from healthcare and cognitive psychology that can inform future research on mitigating the effects of interruptions during diagnostic decision-making. The authors highlight strategies to minimize the negative impacts of interruptions and strategies to prevent distractions altogether; in addition, they propose research priorities within the field of diagnostic safety.
Hawkins RB, Nallamothu BK. BMJ Qual Saf. 2023;32:181-184.
A 2022 study found that non-first off-pump coronary artery bypass graft (CABG) had a higher risk of complications than first cases, proposing prior workload as a contributing cause. This commentary responds to that study, proposing system and organizational factors, not just the individual surgeon, be taken into consideration as contributing causes.
Petts A, Neep M, Thakkalpalli M. Emerg Med Australas. 2022;Epub Dec 5.
Misinterpretation of radiology test results can contribute to diagnostic errors and patient harm. Using a set of 838 pediatric and adult radiographic examinations, this retrospective study found that radiographers’ interpretations can complement emergency clinicians’ interpretations and increase accuracy compared to emergency clinician interpretation alone.
Brattebø G, Flaatten HK. Curr Opin Anaesthesiol. 2023;36:240-245.
Latent errors or conditions are subtle and can be difficult to identify before an incident occurs. This commentary calls for moving from the reactive "bad apple" paradigm to a proactive just culture, where errors and near misses serve as organizational learning opportunities, and not as a time for individual discipline.
Suclupe S, Kitchin J, Sivalingam R, et al. J Patient Saf. 2023;19:117-127.
Patient identification mistakes can have serious consequences. Using the Systems Engineering for Patient Safety (SEIPS) framework, this qualitative study explored systems factors contributing to patient identification errors during intrahospital transfers. The authors found that patient identification was not completed according to hospital policy during any of the 60 observed patient transfer handoffs. Miscommunication and lack of key patient information were common factors contributing to identification errors.
Bates DW, Williams EA. J Allergy Clin Immunol Pract. 2022;10:3141-3144.
Electronic health records (EHRs) are key for the collection of patient care data to inform overarching risk management and improvement strategies. This article discusses the adoption of EHRs as tools supporting patient safety and highlights the need for an expanded technology infrastructure to continue making progress.
Mikhail J, King L. J Patient Saf. 2023;19:99-109.
Early recognition of warning signs of deterioration is key to activating the rapid response system (RRS) and prevention of serious adverse events. This review sought to understand how preparedness of ward-based nurses supports recognition of early warning signs and activation of RRS. Themes include knowledge of criteria to activate the RRS and deference to organizational hierarchy.

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.

Patient Safety Innovation March 29, 2023

With increasing recognition that health is linked to the conditions in which a patient lives, health systems are looking for innovative ways to support recently discharged patients in their lives outside of the hospital. In a recent innovation, Prime Healthcare Services, Inc., which includes a network of 45 hospitals, provided social needs assessments and strengthened its partnerships with community agencies to support the health of high-needs patients after their discharge from the hospital.