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 965 Results

Maryland Hospital Patient Safety Program Annual Report.

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Office of Health Care Quality. Baltimore, MD: Maryland Department of Health and Mental Hygiene.

This annual report summarizes never events in Maryland hospitals over the previous year. During fiscal year 2022, reported events increased due to the COVID pandemic, workforce shortages and other system demands. Events contributing to patient deaths and severe harm from preventable medical errors during the time period doubled. The authors recommend several corrective actions to enhance improvement work, including board and executive leadership engagement in safety work and application of high-reliability concepts to enhance safety culture.

Northwest Patient Safety Conference.

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Washington Patient Safety Coalition. October 17-18, 2023.

The emphasis on improvement solutions rather than counting adverse events is an emerging patient safety strategy. This 20th annual virtual conference will highlight regional and local experiences enhancing patient and family engagement, systems safety, and equitable practice.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

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Patient Safety Innovation July 31, 2023

Concern over patient safety issues associated with inadequate tracking of test results has grown over the last decade, as it can lead to delays in the recognition of abnormal test results and the absence of a tracking system to ensure short-term patient follow-up.^1,2 Missed abnormal tests and the lack of necessary clinical follow-up can lead to a late diagnosis.

Managing near-miss reporting in hospitals: the dynamics between staff members’ willingness to report and management’s handling of near-miss events.

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Caspi H, Perlman Y, Westreich S. Safety Sci. 2023;164:106147.

Near-misses or “good catches” are incidents that could have resulted in patient harm but did not due to it being caught at the last minute or through sheer luck. Reporting near-misses can help organizations learn and enact changes if necessary, but near-misses are not frequently reported. This study presents enablers and barriers to reporting near-misses.

Classification of health information technology safety events in a pediatric tertiary care hospital.

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Khan A, Karavite DJ, Muthu N, et al. J Patient Saf. 2023;19:251-257.

For incidents to be properly addressed, incident reports must be appropriately identified and categorized by safety managers. This study compared the categorization of incidents as involving health information technology (HIT) or not involving HIT by specialists trained in HIT and patient safety and safety managers trained in traditional methods of health safety. Safety managers only agreed with the HIT specialist classification 25% and 75% of the time on incidents involving or not involving HIT, respectively. Increased education for safety managers on the interaction of HIT and patient safety may result in better classification of HIT-related incidents.

A scoping review of distributed cognition in acute care clinical decision-making.

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Wilson E, Daniel M, Rao A, et al. Diagnosis (Berl). 2023;10:68-88.

Clinical decision-making is a complex process often involving interactions with multiple team members, processes, and systems. Using distributed cognition theory and qualitative synthesis, this scoping review including 37 articles identified seven themes addressing how distribution of tasks influences clinical decision-making in acute care settings The themes included information flow, task coordination, team communication, situational awareness, electronic health record (EHR) design, systems-level error, and distributed decision-making.

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

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Patient Safety Innovation May 31, 2023

Seeking a sustainable process to enhance their hospitals’ response to sepsis, a multidisciplinary team at WellSpan Health oversaw the development and implementation of a system that uses customized electronic health record (EHR) alert settings and a team of remote nurses to help frontline staff identify and respond to patients showing signs of sepsis. When the remote nurses, or Central Alerts Team (CAT), receive an alert, they assess the patient’s information and collaborate with the clinical care team to recommend a response.

Learning from errors and resilience.

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Arnal-Velasco D, Heras-Hernando V. Curr Opin Anaesthesiol. 2023;36:376-381.

The Safety II framework and organizational resilience both focus on what goes right in healthcare and adjusting to disturbances through anticipation, monitoring, responding, and learning. This narrative review highlights recent research conducted within a Safety II and resilience framework such as Learning from Excellence and debriefing "what went right" after simulation training. The authors suggest learning from errors or what goes right should be reframed simply as learning.

Thematic reviews of patient safety incidents as a tool for systems thinking: a quality improvement report.

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Machen S. BMJ Open Qual. 2023;12:e002020.

Learning from patient safety incidents can help health care organizations improve processes and care delivery. This article provides a template for organizations to review patient safety incidents and classify them into themes from a human factors and systems thinking perspective. The process involves clearly characterizing the safety incidents, describing the involved safety systems, identifying and classifying contributing factors, completion of narrative analysis to identify commonalities and differences in the way contributing factors affect the incidents, and identification of safety recommendations.

Curated Libraries

Implementation of Patient Safety Projects Curated Library

May 4, 2023

The implementation of effective patient safety initiatives is challenging due to the complexity of the health care environment. This curated library shares resources summarizing overarching ideas and strategies that can aid in successful program execution, establishment, and sustainability.

Understanding complexity in a safety critical setting: a systems approach to medication administration.

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Stevens EL, Hulme A, Goode N, et al. Appl Ergon. 2023;110:104000.

Medication administration is a complex process with many opportunities for error. Using the Event Analysis of Systemic Teamwork (EAST) model, researchers identified opportunities to improve medication administration system performance and promote patient safety. The authors discuss the networks involved in medication administration (e.g., task network, social network, information network) and how the complexities involved in each network contribute to medication administration errors.

Patient Safety Indicators.

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Patient Safety Primer April 26, 2023

Patient safety indicators are tools used to assess the frequency, severity, and impact of potential harms in health care, both within health care organizations and at the health care system, regional, and national levels. This primer describes how patient safety indicators are applied in acute, ambulatory, and post-acute care settings and how these indicators are being incorporated into new federal healthcare quality measurement initiatives.

Integrating implementation science in a quality and patient safety improvement learning collaborative: essential ingredients and impact.

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Jeffs L, Bruno F, Zeng RL, et al. Jt Comm J Qual Patient Saf. 2023;49:255-264.

Implementation science is the practice of applying research to healthcare policies and practices. This study explores the role of implementation science in the success of quality improvement projects. Inclusion of expert implementation specialists and coaches were identified as best practices for successful quality improvement and patient safety projects. COVID-19 presented challenges for some facilities, however, including halting previously successful projects.

Patient safety in the operating room.

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Wahr JA. UpToDate. March 31, 2023.

The operating room is a high-risk environment influenced by culture, teamwork, and task complexity. This review provides an overview of patient safety challenges in the operating room and highlights key approaches for improvement such as system engineering, collaboration, and checklists.

I’m an ER doctor: here’s what I found when I asked ChatGPT to diagnose my patients.

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Tamayo-Sarver J. Fast Company. March 13, 2023.

Artificial intelligence (AI) harbors risks and biases that can misinform clinicians, researchers, and patients. This article discusses experience with an AI application in the emergency setting and the diagnostic mistakes it made. The author offers caution when proceeding with the use of AI as a diagnostic tool.

National Healthcare Quality and Disparities Report Chartbook on Patient Safety.

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Rockville, MD: Agency for Healthcare Research and Quality; March 2023. AHRQ Pub. No. 23-0032.

The Network of Patient Safety Databases (NPSD) serves a central role in understanding the current state of care as tracked by patient safety measures. The 2023 Chartbook offers an overview of nonidentifiable, aggregated patient safety event, and near-miss information, voluntarily reported to data collection initiatives across the United States between 2000 and 2020. The Chartbook includes a summary of trends, disparities findings, and figures illustrating select patient safety measures.

Patient safety and the question of dignitary harms.

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Mitchell P, Cribb A, Entwistle VA. J Med Philos. 2023;48:33-49.

While preventable physical harm, such those from as wrong-site surgery or medication errors, have been the main focus of the patient safety movement, less attention has been paid to preventable psychological, or dignitary, harms. In this commentary, the authors present how dignitary harms do, and do not, fit into the patient safety field and how they can be addressed.

Top 10 Patient Safety Concerns.

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Plymouth Meeting, PA: ECRI; March 2023.

The global COVID-19 pandemic continues to exacerbate weaknesses in care that can contribute to harm. ECRI presents the top ten patient concerns for 2023, including pediatric mental health care, workplace violence, care coordination, and patient medication list mistakes.

Curated Libraries

Value and Patient Safety

March 8, 2023

Value as an element of patient safety is emerging as an approach to prioritize and evaluate improvement actions. This library highlights resources that explore the business case for cost effective, efficient and impactful efforts to reduce medical errors.

The relationship between safety climate and safety performance: a review.

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Syed-Yahya SNN, Idris MA, Noblet AJ. J Safety Res. 2022;83:105-118.

A culture of safety is foundational to successful patient safety initiatives. This systematic review explored the relationship between safety climate and safety-related behaviors across various industries, including healthcare.

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