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 971 Results

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.

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.

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.

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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.

Who are the Numbers – Valuing Transparency in Medical Errors.

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Hospital Quality Institute. March 15, 2023. 2:00-3:00 PM (eastern).

Openness after adverse events is an important avenue toward patient, family, and clinician healing. This session will highlight the value of effective apology and transparency as personal strategies in response to errors. Recommendations to see the personal side of individuals involved in patient safety incidents will be discussed to add value to the use of incident-related data.

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.

‘Ladder’-based safety culture assessments inversely predict safety outcomes.

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Boskeljon‐Horst L, Sillem S, Dekker SWA. J Contingencies Crisis Manag. 2022;Epub Dec 27.

High-reliability organizations frequently assess the strength of their safety culture. In this article, researchers compare the results of a safety culture assessment (SCA) of a helicopter squadron and investigation of an accident that occurred shortly after survey administration. Results of the SCA showed the safety culture was mature, but the investigation revealed otherwise, indicating the SCA had little predictive value.

Toward the translation of systems thinking methods in patient safety practice: assessing the validity of Net-HARMS and AcciMap.

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Salmon PM, King B, Hulme A, et al. Safety Sci. 2022;159:106003.

Organizations are encouraged to proactively identify patient safety risks and learn from failures. This article describes validity testing of systems-thinking risk assessment (Net-HARMS) to identify risks associated with patient medication administration and an accident analysis method (AcciMap) to analyze a medication administration error.

The Joint Commission and National Quality Forum Announce 2022 Eisenberg Award Recipients.

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Oakbrook Terrace, IL: Joint Commission and National Quality Forum: January 23, 2023.

The annual Eisenberg Award recognizes leaders and organizations who have made substantial contributions toward patient safety and quality improvement. The 2022 honorees are Jason S. Adelman, MD, MS, North American Partners in Anesthesia (NAPA) and Parkland Health, Dallas County, Texas. The awards will be presented at the National Quality Forum's annual conference on February 20, 2023, in Washington, DC.

2023 IHI Patient Safety Congress.

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Institute for Healthcare Improvement. Gaylord National Resort and Convention Center, National Harbor, MD, May 22–24, 2023.

This annual conference will host pre-session workshops, panels, and presentations covering a variety of patient safety topics that align with the national agenda for patient safety improvement such as learning systems and leadership. Sessions will take place in-person.

Driving Learning and Improvement After RCA2 Event Reviews.

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Collaborative for Accountability and Improvement. January 26, 2023.

Root cause analysis (RCA) is a recognized approach to examining failures by identifying causal factors to define improvement effort. This session discussed challenges to the effective use of RCA results and examine an approach to present them that supports effective improvement action.

Request for Information: Creating a National Healthcare System Action Alliance to Advance Patient Safety.

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Agency for Healthcare Research and Quality. Fed Register. December 12, 2022;87:76046-76048.

Partnerships are needed to motivate, design, and implement lasting innovation in complex situations. This announcement calls for stakeholder insights on the work of the National Healthcare System Action Alliance to Advance Patient Safety and how it can best realize its mission and goals. The deadline for submitting comments has passed.

Quality improvement as a primary approach to change in healthcare: a precarious, self-limiting choice?

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Mandel KE, Cady SH. BMJ Qual Saf. 2022;31:860-866.

Successful quality improvement (QI) initiatives should encourage change at the individual, team, and organizational levels. The authors of this article summarize the “self-limiting cascade” of quality improvement approaches, whereby QI programs prioritize process-technical strengths (e.g., quality metrics, “zero harm” goals) over participants’ emotional experience and sociotechnical design elements, which can ultimately hinder program performance.

Psychosocial factors and safety in high-risk industries: a systematic literature review.

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Derdowski LA, Mathisen GE. Safety Sci. 2022;157:105948.

Work-related psychosocial factors may increase or decrease the risk of accidents in high-risk industries (e.g., nuclear, mining, healthcare). Using the Job Demands-Resources (JD-R) framework as a starting point, associations between job demands and resources, and between safety behaviors and outcomes were evaluated. Most studies report on the link between psychosocial factors and safety behavior (e.g., job stress or exhaustion can precede negative safety behavior).

Crisis preparedness: a systems-based framework for avoiding harm in surgery.

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Gogalniceanu P, Karydis N, Costan V-V, et al. J Am Coll Surg. 2022;235:612-623.

Safety strategies from high-reliability industries such as aviation and nuclear power are frequently adapted for healthcare. In this study, pilots described crisis preparedness strategies, which surgical safety experts then developed into a framework consisting of six behavioral interventions: anticipate threats, briefing, checklists, drill rehearsal, individual and team empowerment, and debriefing. An earlier study by the authors describes the second phase in managing crisis: crisis recovery.

Reducing adverse obstetrical outcomes through safety sciences.

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Ennen CS, Satin AJ. UpToDate. November 17, 2022.

This review explores the evidence on integrating teamwork, simulation, and unit-based programs to improve safety in obstetrics settings. The authors highlight the need for more data regarding the impact of these approaches on patient outcomes.

Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions

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Perspective on Safety November 16, 2022

Human factors engineering or ergonomics (HFE) is a scientific discipline broadly focused on interactions among humans and other elements of a system.

Ethical leadership supports safety voice by increasing risk perception and reducing ethical ambiguity: evidence from the COVID-19 pandemic.

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Cakir MS, Wardman JK, Trautrims A. Risk Anal. 2022;Epub Oct 19.

Transparency, communication, and value alignment between staff and leaders increase staff trust and comfort in speaking up about concerns. This study describes the relationship of employees’ perception of ethical leadership (manager sets an example of ethical behavior), safety voice (comfort speaking up about COVID-19), ethical ambiguity regarding work responsibilities, and risk perception of coronavirus. Employees who rated their leaders as behaving more ethically were more comfortable speaking up about COVID-19 concerns.

How to induce an error management climate: experimental evidence from newly formed teams.

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Horvath D, Keith N, Klamar A, et al. J Bus Psychol. 2022;Epub Jul 26.

Error management, as opposed to error avoidance, has been shown to improve transfer of skills from training to practice. This study compared two interventions to induce error management (direct or indirect encouragement to learn from errors) and error avoidance. As hypothesized, participants in the error management groups performed better, particularly those in the indirect error management intervention.

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