Skip to main content

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.

Search All Content

Search Tips
Save
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Additional Filters
Displaying 1 - 20 of 345 Results
Gillissen A, Kochanek T, Zupanic M, et al. Diagnosis (Berl). 2022;Epub Nov 9.
Medical students do not always feel competent when it comes to patient safety concepts. In this study of German medical students, most understood the importance of patient safety, though few could identify concrete patient safety topics, such as near miss events or conditions that contribute to errors. Incorporating patient safety formally into medical education could improve students’ competence in these concepts.
Armstrong-Mensah E, Rasheed N, Williams D, et al. J Racial Ethn Health Disparities. 2022;Epub Nov 4.
Black patients who experience racism from their providers report receiving lower quality of care. Black public health students were asked about racist behaviors exhibited by their healthcare providers and the impacts the behaviors had on their care. The students recommend education and accountability to reduce providers’ racist attitudes, as well as increasing the number of Black clinicians.  

REPAIR Project Steering Committee. Acad Med. 2022;97(12):1753-1759. 

The REPAIR (REParations and Anti-Institutional Racism) Project at the University of California, San Francisco, aims to repair racial injustices in medical care and research. This article discusses the development of the initiative, the three annual themes (reparations, abolition, decolonization), and outcomes from its first year.
Smith WR, Valrie C, Sisler I. Hematol Oncol Clin North Am. 2022;36:1063-1076.
Racism exacerbates health disparities and threatens patient safety. This article summarizes the relationship between structural racism and health disparities in the United States and highlights how racism impacts health care delivery and health outcomes for patients with sickle cell disease.
Vogt L, Stoyanov S, Bergs J, et al. J Patient Saf. 2022;18:731-737.
Training in patient safety concepts is an important element of health professional education. This article describes learning objectives on patient safety generated by experts on patient safety and medical education. These learning objectives showed high correspondence with the WHO Patient Safety Curriculum Guide’s learning objectives.
Feldman N, Volz N, Snow T, et al. J Patient Saf Risk Manag. 2022;27:229-233.
Research with medical and surgical residents has shown they are frequently reluctant to speak up about safety and unprofessional behavior they observe. This study asked emergency medicine residents about their speaking up behaviors. Using the Speaking Up Climate (SUC)-Safe and SUC-Prof surveys, residents reported generally neutral responses to speaking up, more favorable than their medical and surgical counterparts. In line with other studies, residents were more likely to speak up about patient safety than about unprofessional behaviors.
Leitman IM, Muller D, Miller S, et al. JAMA Netw Open. 2022;5:e2244661.
The effectiveness of incident reporting systems is hindered by underreporting. This cohort study describes the characteristics of incident reports submitted by trainees in a large academic medical center. From October 2019 through December 2021, trainees submitted nearly 200 incident reports, primarily describing unprofessional interactions. Findings suggest that awareness and support for the online incident reporting system among trainees was high.
Farrell TW, Hung WW, Unroe KT, et al. J Am Geriatr Soc. 2022;70:3366-3377.
Research into the impact of racism on health outcomes has increased in recent years, but there has been less emphasis on ageism or the intersection of ageism and racism. This commentary highlights the ways racism (e.g., clinical algorithms), ageism (e.g., proposed measures to ration care) and the intersection of the two (increased morbidity and mortality of COVID-19 on older people of color) impacts health outcomes. Recommendations for current clinicians and health profession educators are provided.
M. Violato E. Can J Respir Ther. 2022;58:137-142.
Healthcare trainees and junior clinicians are often reluctant to speak up about safety concerns. This qualitative study found that simulation training to enhance speaking up behaviors had lasting effects among advanced care paramedics and respiratory therapists as they moved from training into practice. Respondents highlighted the importance of experience for speaking up and the benefits of high-impact simulation training.
Silva B, Ožvačić Adžić Z, Vanden Bussche P, et al. Int J Environ Res Public Health. 2022;19:10515.
The COVID-19 pandemic led to dramatic changes in healthcare delivery. The multi-country PRICOV-19 study evaluated how primary care practices reorganized their day-to-day work during the pandemic and the impacts on patient safety culture. This study compared training vs. non-training primary care practices and found that training practices had a stronger safety culture during the pandemic.
McGurgan PM, Calvert KL, Nathan EA, et al. J Patient Saf. 2022;18:e1124-e1134.
This survey compared factors influencing opinions about patient-safety-related behaviors among medical students and physicians compared to the general public in Australia. Respondents had significantly different opinions on several of the hypothetical patient safety scenarios used in the survey. Findings suggest that physician and medical student opinions are often influenced by cognitive dissonance, biases, and heuristics.
Van Wassenhove W, Foussard C, Dekker SWA, et al. Safety Sci. 2022;154:105835.
Proficient safety professionals are the cornerstone of effective patient safety programs. In this study, safety professionals provided insights about theoretical factors influencing the role of safety professionals in healthcare (e.g., legal regulation, organizational context, safety culture).

Rockville, MD: Agency for Healthcare Research and Quality; October 2022. AHRQ Publication no. 22(23)-0047-2-EF.

Delayed, wrong, and missed diagnoses are common challenges for patients, families, and clinicians, yet physicians rarely receive feedback on their actions to enhance diagnostic decision making. This publication provides clinicians with tools to assess and calibrate diagnostic performance in support of individual learning and improvement.

Rockville, MD: Agency for Healthcare Research and Quality; September 2022. AHRQ Publication No. 22-0026-3-EF.

Correct consideration of the likelihood that a patient may have a potential disease guides each level of diagnostic decision making; misjudgments can be fatal. This issue brief introduces an information-focused framework to examine how clinicians determine probability and discusses educational avenues for enhancing those skills. The publication is part of a report series on diagnostic safety.
Ghaith S, Campbell RL, Pollock JR, et al. Healthcare (Basel). 2022;10:1328.
Obstetric and gynecologic (OB/GYN) physicians are frequently involved in malpractice lawsuits, some of which result in catastrophic payouts. This study categorized malpractice claims involving OB/GYN trainees (students, residents, and fellows) between 1986 and 2020. Cases are categorized by type of injury, patient outcome, category of error, outcome of lawsuit, and amount of settlement.
Stake-Nilsson K, Almstedt M, Fransson G, et al. BMC Nurs. 2022;21:123.
Medication dose errors can lead to serious adverse events. This systematic review concluded that digital technologies – such as dosing calculators, web-based courses, simulation, and personal digital assistants – can reduce medication dosing errors among nursing students.
Taylor DJ, Goodwin D. J Med Ethics. 2022;48:672-677.
Normalization of deviance describes a situation where individuals, teams or organizations accept a lower standard of performance until that lower standard becomes the “norm” and can threaten patient safety. This article describes five serious medical errors in obstetrics and highlights how normalization of deviance contributed to each event.
Arkin L, Schuermann A, Penoyer D, et al. J Nurs Care Qual. 2022;37:319-326.
Nurses are responsible for several steps in the medication-use process, including preparation, administration, and monitoring of most medications. This study queried nurses working at a 10-hospital system in the southeastern United States about their attitudes, beliefs, and skills surrounding medication safety and error reporting. Survey responses indicate that nurses felt comfortable completing an incident report regarding an error and disclosing the error to another health care provider. There was some ambiguity around rating the severity of hypothetical errors.
Violato E. Adv Health Sci Educ Theory Pract. 2022;27:1177-1194.
Speaking up behaviors are a key indicator of psychological safety and a culture of safety. This article synthesizes the evidence on various aspects of speaking up behavior, including effective interventions to encourage speaking up, factors that positively influence speaking up, and the role of simulation training to develop speaking up skills.