Skip to main content

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.

Search All Content

Search Tips
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Search By Author(s)
Additional Filters
Displaying 1 - 13 of 13 Results
WebM&M Case June 14, 2023

A 25-year-old female was sent by ambulance to the emergency department (ED) by a mental health clinic for suicidal ideation. Upon arrival to the ED, she was evaluated by the triage nurse and determined to be awake, alert, calm, and cooperative and she denied current suicidal thoughts. The ED was extremely busy, and the patient was placed on a gurney with a Posey restraint in the hallway next to the triage station awaiting psychiatric social work assessment. Approximately 40 minutes later, the triage nurse noticed that the patient was missing from the gurney.

Anderson E, Mohr DC, Regenbogen I, et al. J Patient Saf. 2021;17:316-322.
Burnout and low staff morale have been associated with poor patient safety outcomes. This study focused on the association between organizational climate, burnout and morale, and the use of seclusion and restraints in inpatient psychiatric hospitals. The authors recommend that initiatives aimed at reducing restraints and seclusion in inpatient psychiatric facilities also include a component aimed at improving organizational climate and staff morale.
Tölli S, Kontio R, Partanen P, et al. Perspect Psychiatr Care. 2020;56:785-796.
This study used qualitative methods to understand the experiences of former psychiatric patients that nursing staff considered challenging and that resulted in behavior management interventions (e.g., aggression, self-harm, inappropriate sexual behavior). Interviewed patients cited various reasons for these challenging behaviors, including communication difficulties related to their psychiatric symptoms, stressful feelings such as frustration and fear, coercive nursing culture and restrictive nursing practices. Strategies for managing these behaviors are discussed, as well as core competencies for delivering care based on patients’ needs.
Thibaut BI, Dewa LH, Ramtale SC, et al. BMJ Open. 2019;9:e030230.
This exploratory systematic review aimed to describe the state of the research on patient safety in inpatient mental health settings. Authors included 364 papers, representing 31 countries and data from over 150,000 participants. The existing research base was categorized into ten broad safety categories – interpersonal violence, coercive interventions, safety culture, harm to self, safety of the physical environment, medication safety, unauthorized leave, clinical decision making, falls, and infection prevention/control; papers were of varying quality with the majority of papers assessed as “fair”. The authors note that several areas of patient safety in inpatient mental health are particularly understudied, such as suicide, as the review only yielded one study meeting inclusion criteria.
Patient Safety Primer September 7, 2019
The list of never events has expanded over time to include adverse events that are unambiguous, serious, and usually preventable. While most are rare, when never events occur, they are devastating to patients and indicate serious underlying organizational safety problems.
Hall DK, Zimbro KS, Maduro RS, et al. J Nurs Care Qual. 2018;33:143-148.
Although physical restraints may be used to protect patients in intensive care units from falls and other accidents, inappropriate restraint use can contribute to adverse events. This commentary describes how one hospital implemented a program using education and team communication tactics to reduce opportunities for patient harm associated with restraint use.
Parikh R. The Atlantic. August 18, 2014.
The inappropriate use of physical restraints on patients is considered a sentinel event. Although restraints may be used to protect patients from harm, this magazine article highlights risks related to their use—such as increased rates of pressure ulcers and delirium—and advocates for a more patient-sensitive approach to ensure the safety of both patients and caregivers.
Byrnes MC, Schuerer DJE, Schallom ME, et al. Crit Care Med. 2009;37:2775-81.
Adoption of checklists to standardize and mitigate error-prone processes was popularized in patient safety through a compelling 2007 New Yorker article. The concept was further supported by its resounding success in preventing central-line–associated bloodstream infections. Similar efforts have emerged in surgical settings in which adoption of a specific checklist reduced morbidity and mortality. This study implemented a 14-point checklist in the intensive care unit (ICU) setting to actively engage providers in considering best practices during daily rounds and then evaluated whether the checklist affected practice patterns. While the study did not measure clinical patient outcomes, investigators did demonstrate significant improvements in deep vein thrombosis and stress ulcer prophylaxis, oral care for ventilated patients, electrolyte repletion, initiation of physical therapy, and documentation of restraint orders. The study also demonstrated a two-fold increase in transferring patients out of the ICU on telemetry compared with baseline practice. The authors advocate for use of this cost-effective method to promote best practices in ICU settings.
Griffey RT, Wittels K, Gilboy N, et al. Ann Emerg Med. 2009;53:469-76.
Computerized reminders to renew orders for physical restraints were combined with a forcing function—denial of computer access until the order was completed—in this trial conducted in an emergency department. Although clinician ordering behavior improved, no significant improvement was found in the amount of time patients spent in restraints.
Nawaz H, Abbas A, Sarfraz A, et al. J Hosp Med. 2007;2:385-393.
Using physical restraints is a common method to prevent injury in agitated hospitalized patients, but it also can lead to undesired outcomes. This study showed that the SOMA Safe EnclosureTM appears to be a safe, effective type of restraint that is more acceptable to family members and physicians than the types of restraints currently in use.