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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 153 Results
Seys D, Panella M, Russotto S, et al. BMC Health Serv Res. 2023;23:816.
Clinicians who are involved in a patient safety incident can experience psychological harm. This literature review of 104 studies identified five levels of support that can be provided to healthcare workers after a patient safety incident – (1) prevention, (2) self-care of individuals and/or teams, (3) support by peers and triage, (4) structured professional support, and (5) structured clinical support.
Nosanov L, Elseth AJ, Maxwell J, et al. Am J Surg. 2023;Epub Jul 3.
The second victim concept encompasses an important concern for the impact of unsafe care on health care workers. This commentary discusses the topic and the need for system-level solutions to ensure surgical team members involved with patient harm due to errors can heal, and in doing so, provide safe care to their patients.
Schrøder K, Assing Hvidt E. Int J Environ Res Public Health. 2023;20:5749.
Healthcare providers may experience emotional distress after involvement in an adverse or traumatic event. This qualitative study with 198 healthcare professionals identified common emotions experienced after adverse events as well as the types of support needed after involvement in an adverse event. These findings can contribute to the development and refinement of support programs for healthcare workers after adverse events.
Øyri SF, Søreide K, Søreide E, et al. BMJ Open Qual. 2023;12:e002368.
Reporting and learning from adverse events are core components of patient safety. In this qualitative study involving 15 surgeons from four academic hospitals in Norway, researchers identified several individual and structural factors influencing serious adverse events as well as both positive and negative implications of transparency regarding adverse events. The authors highlight the importance of systemic learning and structural changes to foster psychological safety and create space for safe discussions after adverse events.
Allender EA, Bottema SM, Bosley CL, et al. Respir Care. 2023;68:749-759.
After unanticipated adverse events, healthcare providers may experience negative emotions, such as sadness, anxiety, or anger, sometimes referred to as the "second victim" experience (SVE). In this study of 171 respiratory therapists, more than half reported they had been part of an event that resulted in SVE. Nearly three-quarters reported that short staffing played a role in their emotional distress, and half indicated COVID-19 contributed to their SVE. In line with other studies, the most desired type of support following an adverse event was talking to a peer.
Perspective on Safety March 21, 2023

Throughout 2022, the impact of system failures on healthcare workers was a recurrent theme of articles on AHRQ PSNet. This Year in Review explores these impacts and ways to support healthcare workers involved in a system failure.  

Throughout 2022, the impact of system failures on healthcare workers was a recurrent theme of articles on AHRQ PSNet. This Year in Review explores these impacts and ways to support healthcare workers involved in a system failure.  

Mambrey V, Angerer P, Loerbroks A. BMC Health Serv Res. 2022;22:1501.
Committing errors can result in significant emotional impact on clinicians. In this study, a survey of medical assistants in Germany found that poor collaboration was a key predictor of concerns for having committed a medical error.
Vanhaecht K, Seys D, Russotto S, et al. Int J Environ Res Public Health. 2022;19:16869.
‘Second victim’ is controversial term used to describe health care professionals who experience continuing psychological harm after involvement in a medical error or adverse event. In this study, an expert panel reviewed existing definitions of ‘second victim’ in the literature and proposed a new consensus-based definition.
Bushuven S, Trifunovic-Koenig M, Bentele M, et al. Int J Environ Res Public Health. 2022;19:16016.
Healthcare workers (HCWs) who are involved in serious adverse events may feel traumatized by those events, and many organizations have implemented “second victim” training programs to support their workers. This study sought to understand HCWs’ motivations to attend such trainings and a potential association with overconfidence. Understanding the association may help organizations develop effective training programs and increase motivation to attend them.
Aubin DL, Soprovich A, Diaz Carvallo F, et al. BMJ Open Qual. 2022;11:e002004.
Healthcare workers (HCW) and patients can experience negative psychological impacts following medical error; the negative impact can be compounded when workers and patients are prevented from processing the error. This study explored interactions between patients/families and HCWs following a medical error, highlighting barriers to communication, as well as the need for training and peer support for HCWs. Importantly, HCW and patients/families expressed feeling empathy towards the other and stressed that open communication can lead to healing for some.
Pado K, Fraus K, Mulhem E, et al. J Clin Psychol Med Settings. 2022;Epub Dec 12.
Medical errors may lead to feelings of distress for clinicians, but these errors can also be an opportunity for growth. This study used the Second Victim Experience and Support Tool (SVEST) and the Posttraumatic Growth Inventory to assess the extent, if any, of growth following a medical mishap. Rumination and the impact of the medical mishap were associated with distress among both physicians and nurses. The impact of the event was associated with growth in nurses, but no factor was associated with growth in physicians.
Mahat S, Rafferty AM, Vehviläinen-Julkunen K, et al. BMC Health Serv Res. 2022;22:1474.
Healthcare staff who are involved in a medical error often experience emotional distress. Using qualitative methods and text mining of medication error incident reports, researchers in this study identified the negative emotions experienced by healthcare staff after a medication error (e.g., fear, guilt, sadness) and perceptions regarding how superiors and colleagues effectively responded to the events (e.g., reassurance, support, and guidance).
Chen S, Skidmore S, Ferrigno BN, et al. J Thorac Cardiovasc Surg. 2023;166:890-894.
“Second victims” are healthcare providers and support staff involved in an unexpected adverse event and experience continuing psychological harm. While some hospitals provide formal support for “second victims,” it is frequently underutilized. In addition to implementing (and improving) formal support programs, this commentary also encourages a culture of safety and understanding of the 6-stage pathway toward recovery.
Fleming EA. JAMA. 2022;328:1297-1298.
Honest apology is known to support healing from medical error for clinicians, patients, and families. This essay shares the experience of one physician who missed signs of a heart attack, mislabeling the condition as fatigue, who then apologized for the mistake. The author highlights how openness about the error was crucial in the continuation of the care relationship.
Seys D, De Decker E, Waelkens H, et al. J Patient Saf. 2022;18:717-721.
Burnout and stress among healthcare workers can adversely impact patient safety. Using data from two cross-sectional surveys, this study found the COVID-19 pandemic had a larger impact on the mental health and well-being of healthcare workers compared to involvement in a patient safety incident. Negative psychological symptoms such as anxiety, sleep deprivation, and wanting to leave the profession were all significantly higher in COVID-19-related groups. 
Lin JS, Olutoye OO, Samora JB. J Pediatr Surg. 2023;58:496-502.
Clinicians involved in adverse events may experience feelings of guilt, shame, and inadequacy; this is referred to as “second victim” phenomenon. In this study of pediatric surgeons and surgical trainees, 84% experienced a poor patient outcome. Responses to the adverse event varied by level of experience (e.g., resident, attending), gender, and age.
Harrison R, Johnson J, Mcmullan RD, et al. J Patient Saf. 2022;18:587-604.
Providers who are involved in a medial error may experience a range of negative emotions and utilize a variety of coping mechanisms following the error. The authors update their 2010 systematic review on medical professionals’ coping with medical error and apply their Recovery from Situations of Error Theory (ReSET) model. The ReSET model provides a basis to develop and evaluate interventions to reduce feelings of distress and increase providers’ coping skills.

Neft MW, Sekula K, Zoucha R, et al. AANA J. 2022;90(3):189-196. 

Healthcare workers who are involved in a patient safety incident may experience adverse psychological outcomes. This integrative review summarizes the importance of organizational safety culture and highlights strategies and programs (such as the RISE support program and peer support teams) for supporting healthcare professionals after involvement in a patient safety incident.
Gupta K, Rivadeneira NA, Lisker S, et al. J Patient Saf. 2022;18:531-538.
Strategies to reduce clinician burnout related to adverse events are critically needed. Physicians in the United States were surveyed on their experiences with adverse events to identify facilitators and barriers to reducing burnout. A common facilitator was peer support, and barriers included shame and a punitive work environment.
Buhlmann M, Ewens B, Rashidi A. J Adv Nurs. 2022;78:2960-2972.
The term “second victims” describes clinicians who experience emotional or physical distress following involvement in an adverse event. Nurses and midwives were interviewed about “moving on” from the impact of a critical incident. Five main themes were identified: Initial emotional and physical response, the aftermath, long-lasting repercussions, workplace support, and moving on. Lack of organizational support exacerbated the nurses’ and midwives’ responses.