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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 733 Results
Montalmant KE, Ettinger AK. J Racial Ethn Health Disparities. 2023;Epub Nov 13.
The increased risk of maternal morbidity and mortality among Black women in the United States is a patient safety and public health crisis. This literature review of 42 articles highlights the importance of cultural competence and disparities training for obstetric providers to reduce maternal mortality and morbidity among Black women. The authors also highlight the need for increased awareness regarding the increased risk of cardiovascular diseases among pregnant Black women.
Weaver MD, Barger LK, Sullivan JP, et al. Sleep Health. 2023;Epub Nov 6.
Current Accreditation Council for Graduate Medical Education (ACGME) duty hour regulations limit resident work hours (no more than 80 hours per week or 24-28 consecutive hours on duty) in an effort to improve both resident and patient safety. This nationally representative survey found that over 90% of US adults disagree with the current duty hour policies, with 66% of respondents supporting additional limits on duty hours (to no more than 40 hours per week or 12 consecutive hours).
Krogh TB, Mielke-Christensen A, Madsen MD, et al. BMC Med Educ. 2023;23:786.
Medical trainees suffer from "second victim syndrome" (SVS) at rates similar to practicing healthcare professionals but they may not have the same resources to recover. This study of medical students' experiences describes the usual triggers of SVS such as patient harm, but also from negative responses by supervising physicians. Formal instruction and open discussion of SVS can support students' well-being and recovery.
Mohamed I, Hom GL, Jiang S, et al. Acad Radiol. 2023;Epub Sep 22.
Psychological safety is an important principle in identifying problems and improving patient outcomes. This narrative review highlights five best practices to foster psychological safety in radiology residencies – (1) establish clear goals and educational strategies, (2) build a formal mentoring program, (3) assess psychological safety, (4) advocate for radiologists as educators, and (5) support non-radiology staff. Although the review focuses on radiology residency programs, these strategies can be adapted to any residency program.
Beaulieu-Jones BR, Wilson S, Howard DS, et al. JAMA Surg. 2023;Epub Oct 18.
Morbidity and Mortality Conferences (MMC) have a long history in medical education and error analysis. This review summarizes MMC best practices to optimize format and design to advance trainee education and format. Four overarching themes emerged, including formal preparation in advance of the MMC, a balance of presentation and discussion, formal channels for quality improvement and education, and an emphasis on safety culture.
Kalfsvel L, Wilkes S, van der Kuy H, et al. Eur J Hosp Pharm. 2023;Epub Aug 31.
Even with the use of clinical decision support systems (CDSS), clinicians can still make medication prescribing errors. This study compared frequency, type, and severity of prescribing errors between junior doctors (i.e., those in training with less than 10 years’ work experience) and consultants (i.e., not in training with 10 or more years of work experience).  Overall prescribing errors were low, but junior doctors made more errors than consultants. They also made different types of errors, with junior doctors more likely to make drug-drug interaction errors and consultants making duplication therapy errors. There were no differences in severity of errors. Early education and training with computerized provider order entry (CPOE) and CDSS may reduce errors made by doctors in training.
Huang KX, Chen CK, Pessegueiro AM, et al. J Hosp Med. 2023;18:888-895.
Interdisciplinary rounds have been shown to improve patient outcomes such as shorter length of stay. In this study, more than 1,000 interdisciplinary rounds were observed to assess the extent and timing of physician-nurse communication. Results show attending physicians had longer interaction times with nurses than did residents or interns. Attendings were also more likely to elicit nurses' concerns rather than waiting for nurses to bring them up. These findings show the importance of including attendings in bedside rounds and medical schools could stress the importance of interdisciplinary rounds and teamwork.
Bagian JP, Paull DE, DeRosier JM. Surg Open Sci. 2023;16:33-36.
The Accreditation Council for Graduate Medical Education (ACGME) requires post-graduate education to include patient safety curriculum. This article describes the development and evaluation of a curriculum for residents on patient safety investigations using the Root Cause Analysis and Action (RCA2) model. Residents were surveyed at least one year after completion of the training. Sixty-three percent of respondents agreed or strongly agreed residents should be provided with the RCA2 training and nearly half reported having participated on an RCA team since completing the program.
Richards JL, Brook K. Postgrad Med J. 2023;Epub Sep 19.
Healthcare organizations are implementing various interventions to reduce clinician burnout and mitigate associated harms. This article describes the influence of financial wellness on physician burnout and suggests that medical schools and healthcare organizations implement strategies to increase physician financial literacy as one approach to reducing burnout.
Harrison J. Br Paramed J. 2023;8:18-28.
Patients with dark skin tones are not well represented in health education, particularly dermatology, which can result in delayed diagnosis. In this scoping review, thirteen articles were identified assessing the confidence of students and healthcare providers in assessing patients with dark skin tones.  Overall, confidence was low but tailored training somewhat improved confidence. The author asserts more research and education is needed outside dermatology, for example, when assessments use terms such as pale, redness, or blue.
Yartsev A, Yang F. Simul Healthc. 2023;18:279-282.
Intensive care units (ICUs) are complex care environments at high risk for medical errors. In this retrospective study, researchers identified the occurrence of common ICU scenarios and skills during code blue events and measured trainees’ self-reported confidence in these skills. The analysis found that more than 25% of trainees reported low levels of confidence in three scenarios – familiarity with the advanced life support trolley, electrocardiogram strip interpretation, and operation of an external defibrillator. This process of integrating critical incident data with trainee self-assessment can be generalized to other clinical scenarios to create targeted education and simulation curriculum.
Brown CE, Snyder CR, Marshall AR, et al. J Gen Intern Med. 2023;Epub Aug 24.
Structural racism continues to perpetuate health disparities. As part of their study on how black patients with serious illness experience racism from providers, researchers conducted interviews with 21 providers to understand ways they address anti-Black racism in their practice. Providers felt unprepared to address racism with their patients, wanted to provide tools for patients to bring up their experiences while also acknowledging the additional burden this would place on Black patients, and thought patient- and provider-facing programs could facilitate discussions. Additionally, despite extensive research on the negative impacts of structural racism on health, participants cited the need for more data.

West S. KFF Health News. August 24, 2023.

The challenge of unsafe maternal care is gaining deserved attention across the system spectrum. This article discusses the preventative nature of many barriers to safe care Black mothers face including lack of health insurance, limited access to prenatal care and disrespect for concerns during care encounters.
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.

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.

Kathleen Sanford

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.

WebM&M Case August 30, 2023

This case describes a 27-year-old primigravid woman who requested neuraxial anesthesia during induction of labor. The anesthesia care provider, who was sleep deprived near the end of a 48-hour call shift (during which they only slept for 3 hours), performed the procedure successfully but injected an analgesic drug that was not appropriate for this indication. As a result, the patient suffered slower onset of analgesia and significant pruritis, and required more prolonged monitoring, than if she had received the correct medication.

Paull DE, Newton RC, Tess AV, et al. J Patient Saf. 2023;19:484-492.
Previous research suggests that residents may underutilize adverse event reporting tools. This article describes an 18-month clinical learning collaborative among 16 sites intended to increase resident and fellow participation in patient safety event investigations. Researchers found the collaborative increased participation in event investigation and improved the quality of the investigation.
Williams SR, Sebok-Syer SS, Caretta-Weyer H, et al. BMC Med Educ. 2023;23:434.
Standardizing handoff training in residency programs can lead to safer, more effective handoffs. Researchers surveyed a sample of 687 residents and fellows from over 30 specialties about handoff training perspectives. Participants reported wide variability in handoff content and identified important aspects of handoff training (critical handoff elements, the impact of systems-level factors, impact of the handoff on providers and patients, professional duty, and addressing blame or guilt related to poor handoff experiences).
Weaver MD, Sullivan JP, Landrigan CP, et al. Jt Comm J Qual Patient Saf. 2023;49:634-647.
The Accreditation Council for Graduate Medical Education (ACGME) restrictions on resident work hours have improved resident well-being, but the impact on education, clinical and patient safety outcomes is less clear. This meta-analysis found that the 2003 ACGME restrictions (limiting residents to 80-hour work weeks and 28-hour shifts) was associated with an 11% reduction in mortality; however, there was no significant difference in mortality after the 2011 restrictions (limiting first-year residents to 16-hour shifts). These findings reinforce the impact of extended resident physician work hours and patient morbidity and mortality. The authors also recommend that future research examine the relationship between work hours and patient outcomes among other health care workers.
Shepherd L, Chilton S, Cristancho SM. Acad Med. 2023;98:934-940.
Learning from mistakes is an important component of medical education. In this study, medical residents at one large Canadian hospital participated in semi-structured interviews exploring how residents experience and learn from medical errors. Residents described learning to differentiate errors from complications, how the work environment and workload creates vulnerabilities, approaches to manage errors, and identifying avenues for support in order to move past an error.