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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 112 Results

Le Coz E. USA Today. October 26, 2023.

Chain pharmacies provide prescriptions in an environment that facilitates error due to production pressures, poor error reporting, and a lack of safety culture. This feature story examines working conditions at primary retail pharmacies in the United States and draws from staff experiences, industry data and frontline evidence to illustrate the problem as a threat to patient safety.
Pogorzelska-Maziarz M, de Cordova PB, Manning ML, et al. Am J Infect Control. 2023;Epub Aug 23.
The COVID-19 pandemic highlighted systemic weaknesses in the healthcare system. This survey of 3,067 registered nurses working in New Jersey used the Donabedian framework to identify challenges related to providing safe care during the pandemic. Respondents identified several organizational factors, including inadequate resources and staffing, which adversely impacted their ability to adhere to patient safety and infection prevention and control protocols during the pandemic.
Labrague LJ. Leadersh Health Serv (Bradf Engl). 2023;Epub Oct 9.
Leadership behaviors have an important impact on the workforce and work environment in both positive and negative ways. This review summarizes how toxic leadership impacts the nursing workforce and patient safety. Within the patient safety theme, toxic leadership was significantly associated with increased falls, nosocomial infections, and medication errors.
Ljungberg Persson C, Nordén Hägg A, Södergård B. Explor Res Clin Soc Pharm. 2023;12:100327.
Increases in clinician workload can increase the risk of medical errors. This survey of Swedish community pharmacists found that while perceived workload increased and work environment decreased during the COVID-19 pandemic, there was no perceived impact on patient safety. Findings underscore the importance of effective communication between management and frontline healthcare workers during crises.

Moore QT, Bruno MA. Radiol Technol. 2023;94(6):409-418.

Fostering a culture of safety is a key objective across all clinical areas, including radiology. This secondary analysis of survey data found that radiologists working night shifts and shifts exceeding 12 hours have poor perceptions of teamwork and of leadership actions concerning radiation safety.
WebM&M Case September 27, 2023

This case describes an older adult patient with generalized abdominal pain who was eventually diagnosed with inoperable bowel necrosis. Although she appeared well and had stable vital signs, triage was delayed due to emergency department (ED) crowding, which is usually a result of hospital crowding. She was under-triaged and waited three hours before any diagnostic studies or interventions commenced. Once she was placed on a hallway gurney laboratory and imaging studies proceeded hastily.

Peterson M. Los Angeles Times. September 5, 2023.

Safe practice in community pharmacy is challenged by production pressure, workforce shortages, and multitasking. This story examined the mistakes made at major retail pharmacy chains in California. It provides examples perpetrated across the industry to target universal areas of needed improvement and potential strategies to address them.
Ivanovic V, Broadhead K, Beck R, et al. AJR Am J Roentgenol. 2023;221:355-362.
Like many clinical areas, a variety of system factors can influence diagnostic error rates in neuroradiology. This study included 564 neuroradiologic examinations with diagnostic error and 1,019 without error. Diagnostic errors were associated with longer interpretation times, higher shift volume, and weekend interpretation.
Imes CC, Tucker SJ, Trinkoff AM, et al. Nurs Adm Q. 2023;47:E38-E53.
Extended and overnight shifts are associated with higher adverse event rates and burnout. This mini review summarizes the impact of overnight shifts on nurses' health, patient and public safety, and organizational costs (e.g., those related to nurse turnover). Organizational strategies to promote nurses' health and reduce errors are also summarized, ranging from low-cost measures such as breaks for physical activity during the shift to high-cost measures such as referral to sleep specialists or paid transportation home.
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.

Loke DE, Green KA, Wessling EG, et al. Jt Comm J Qual Patient Saf. 2023;49:663-670.
Quantitative studies have demonstrated that emergency department (ED) overcrowding and patient boarding contribute to adverse events. This study includes both qualitative and quantitative methods to understand how ED clinicians view the impact of boarding on their own well-being as well as patient safety. Key themes include clinician dissatisfaction and burnout, and high rates of verbal and physical abuse from boarding patients. Possible solutions included improved standardization of care, proactive planning, and culture change hospital-wide.
Kwon K-E, Nam DR, Lee M-S, et al. J Patient Saf. 2023;19:353-361.
Community pharmacists are perhaps the last line of defense in preventing medication errors in the outpatient setting; therefore, ensuring a strong safety culture is critical. This review identified 11 studies reporting on safety culture using the AHRQ Community Pharmacy Survey on Patient Safety Culture. Pharmacists and pharmacy staff rated overall patient safety highly, but more than half identified workload as a concern.
Zińczuk A, Rorat M, Simon K, et al. Viruses. 2023;15:1430.
The COVID-19 pandemic exacerbated many existing patient safety challenges. This retrospective analysis of 477 fatal COVID-19 cases at one hospital in Poland found that one-third of patients experienced a healthcare-acquired infection during their hospitalization as well as other hospital-acquired complications, including thrombolytic and/or bleeding complications, acute kidney injury, and exacerbation of chronic heart disease. The analysis also found that many patients experienced delays in specialist treatment (33%) or lack of specialist treatment (17%) during their hospitalization.
Duhalde H, Bjuresäter K, Karlsson I, et al. Int Emerg Nurs. 2023;69:101296.
Missed nursing care (MNC) refers to needed nursing care that is delayed, partially completed, or not completed at all, and can result in adverse events. This systematic review summarizes missed nursing care in emergency departments (ED). Causes of MNC include overcrowding and patients with complex care needs, which may result in medication errors, pressure injuries, or patient deterioration.
Green MA, McKee M, Hamilton OKL, et al. BMJ. 2023;328:e075133.
Many patients were unable to access care during the pandemic, particularly during surges. This longitudinal cohort study in the UK reports that 35% of participants reported disrupted access to care (e.g., cancelled or postponed appointments or procedures). While overall rates of potentially preventable hospitalization were low (3%), those who reported disrupted access had increased risk of potentially preventable hospitalization.
Abramovich I, Matias B, Norte G, et al. Eur J Anaesthesiol. 2023;40:587-595.
Fatigue and sleep deprivation of anesthesia providers can result in decreased non-technical skills and psychomotor functioning. This study of 1,200 anesthesia and intensive care trainees in Europe describes the impact of work-related fatigue on well-being, commuting, and potential for medical errors. Two-thirds of respondents reported making or nearly making a medical error after working long hours. In addition to implementing shorter work schedules, the authors also encourage a culture where it is acceptable to admit fatigue, and where resting is encouraged.
Berggren K, Ekstedt M, Joelsson‐Alm E, et al. J Clin Nurs. 2023;32:7372-7381.
Intensive care units (ICU) experienced extensive, rapid reorganization at the beginning of the COVID-19 pandemic. This qualitative study of ICU personnel uncovered multiple ways they experienced decreases in patient safety during the initial reorganization. They reported the unfortunate necessity of "cutting safety corners," poorly adapted temporary ICUs, and feelings of increased personal responsibility due to changes in skill mix. Participants reported the care provided was safe, but of lower quality than was typical.
Kim RG, An VVG, Lee SLK, et al. Orthop Traumatol Surg Res. 2023;109:103299.
Overlapping surgery, where “critical” portions of surgery are performed sequentially in separate operating rooms, is used to increase efficiency and number of procedures performed each day. This systematic review and meta-analysis was performed to determine differences in risk of complications between overlapping surgery (OS) and non-overlapping surgery (NOS) in total hip and total knee arthroplasty. Consistent with prior studies and reviews, there were no significant differences in adverse events or complications between OS and NOS. The authors stress that informed consent and patient education prior to OS is critically important.
Petrino R, Tuunainen E, Bruzzone G, et al. Eur J Emerg Med. 2023;30:280-286.
The emergency department is a busy and complex environment that can present challenges to patient safety. This survey of emergency medicine professionals from 101 countries identified several patient safety concerns, including workflow and staffing, overcrowding and perceived lack of leadership support. Two PSNet WebM&M commentaries highlight the impact of boarding and overcrowding in the emergency department on patients with a postoperative infection and ruptured abdominal aortic aneurysm.
Scholliers A, Cornelis S, Tosi M, et al. Br J Anaesth. 2023;130:622-635.
Clinicians often work long hours with irregular schedules, which can contribute to fatigue. This scoping review of 30 studies identified several patient safety risks associated with fatigue in anesthesia providers, including deterioration in non-technical skills, increased medication errors, poor attention and psychomotor decline.