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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 971 Results

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.

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.
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.

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
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.

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.
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.
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.

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.

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.

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.

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.
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.
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).
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.
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.
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.