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 190 Results

AMA Prior Authorization (PA) Physician Survey.

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Chicago, IL: American Medical Association; March 2023.

Insurance policies can have consequences that reduce the safety of medical care. This latest version of the study surveyed 1000 physicians in 2022 to find that prior authorization requirements contributed to patient harm or potentially preventable hospitalization 33 percent of the time.

Crisis in the Lakeshore Hospital ER.

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Derfel A. Montreal Gazette. February 24- March 1, 2023

Emergency room failures are often rooted in system weaknesses. This series examines six patient deaths associated with emergency care that, while concerns were raised by nursing staff, have not been explored to initiate improvements at the facility. Factors contributing to the deaths discussed include nurse shortages, inconsistent oversight, and poor training.

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.

Lessons learned from the RaDonda Vaught ruling.

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Bilski J. Outpatient Surgery. February 2023;16-21

The concept of just culture was challenged in a high-profile medication error resulting in criminal charges for a nurse. This dialogue shares insights on the impact of the case on nurses, their profession, and patient safety.

Measuring Patient Safety

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Perspective on Safety December 14, 2022

This collaborative piece with the Centers for Medicare & Medicaid Services discusses the current state of patient safety measurement, advancements in measuring patient safety, and explores future directions.

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.

In Conversation With... Pascale Carayon, PhD and Nicole Werner, PhD

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Perspective on Safety November 16, 2022

Dr. Pascale Carayon, PhD, is a professor emerita in the Department of Industrial and Systems Engineering and the founding director of the Wisconsin Institute for Healthcare Systems Engineering (WIHSE). Dr. Nicole Werner, PhD, is an associate professor in the Department of Health and Wellness Design at the Indiana University School of Public Health-Bloomington. We spoke with both of them about the role of human factors engineering has in improving healthcare delivery and its role in patient safety.

Failure of crisis leadership in a global pandemic: some reflections on COVID-19 and future recommendations.

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Okoli J, Arroteia NP, Ogunsade AI. Leadersh Health Serv (Bradf Engl). 2022;Epub Sep 22.

At the start of the COVID-19 pandemic, leaders around the world were forced to rapidly made decisions with limited knowledge of the impact those decisions would have on public health. This review of research, policy and the media highlights three cognitive antecedents to crisis leadership failures: 1) ignoring the precautionary principle (e.g., “better safe than sorry”), 2) the illusion of control, and 3) poor uncertainty management tactics. Recommendations for future successful crisis leadership include avoiding optimistic bias, avoiding conflicting information, and frame and communicate risk messages in the right way.

Medical error and vulnerable communities.

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Jean-Pierre P. Boston U Law Rev. 2022; 102(1):327-392.

Bias and discrimination are receiving overdue attention as primary barriers to patient safety. This article discusses medical error, ineffective response to error, social trust and health care, state apology laws and the role of communication and resolution programs (CRP) to reduce additional harms associated with medical errors, all in the context of marginalized populations.

'Reading the Signals' : Maternity and Neonatal Services in East Kent – the Report of the Independent Investigation.

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Kirkup B. Department of Health and Social Care. London, England: Crown Copyright; 2022. ISBN: 9781528636759.

Maternity care is beset with challenges that reduce safety. This analysis provided insights into improving maternity care in the British National Health Service (NHS) focusing on the need for identification of inadequate performance, enhanced sympathetic care, common purpose in teams, honest response to difficulties and effective outcome measurement.

Missed CANDOR Implementation Opportunities.

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WebM&M Case November 16, 2022

A 58-year-old man underwent a complex surgery to replace his aortic valve. The surgery required prolonged cardiopulmonary bypass time and cross-clamp time and there was a short delay in redosing the cardioplegic solution and the patient developed “stone heart” due to suspected ischemic injury and was unable to come off bypass. The patient was placed on extracorporeal membrane oxygenation (ECMO) and transported to the ICU to allow family members to see the patient before stopping life support.

Transparency, public reporting, and a culture of change to quality and safety in cardiac surgery.

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Ibrahim M, Szeto WY, Gutsche J, et al. Ann Thorac Surg. 2022;114:626-635.

Reports of poor care in the media or public reporting systems can serve as an impetus to overhauling hospitals or hospital units. After several unexpected deaths and a drop in several rating systems, this cardiac surgery department launched a comprehensive quality improvement review. This paper describes the major changes made in the department, including role clarity and minimizing variation in 24/7 staffing.

Veterans Health Administration response to the COVID-19 crisis: surveillance to action.

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Charles MA, Yackel EE, Mills PD, et al. J Patient Saf. 2022;18:686-691.

The first surge of the COVID-19 pandemic forced healthcare organizations to respond to patient safety issues in real-time. The Veterans Health Administration’s National Center for Patient Safety established two working groups to rapidly monitor quality and safety issues and make timely recommendations to staff. The formation, activities, and primary themes of safety issues are described.

Position Statement on Criminalization of Medical Error and Call for Action to Prevent Patient Harm from Error.

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Cooper J, Thomas BJ, Rebello E, et al for the APSF Criminalization of Error Task Force. APSF Newsletter. October 2022; 37(3):80-81

Criminalizing human error can deter the transparency necessary to learn from incidents and improve health care. This position statement articulates the importance of avoiding the criminal prosecution to mistakes to instead focus on system failures to prevent conditions that permit errors to harm patients.

Patient safety and legal regulations: a total-scale analysis of the scientific literature.

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Yeung AWK, Kletecka-Pulker M, Klager E, et al. J Patient Saf. 2022;18:e1116-e1123.

Legal and policy approaches are used to achieve sustained safety improvements. This review characterized the body of evidence regarding patient safety and its legal implications. Four approaches to improving safety were commonly covered in the literature – liability system reforms, new forms of regulation, increased transparency, and financial incentives.

Optimizing Pediatric Patient Safety in the Emergency Care Setting.

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Joseph MM, Mahajan P, Snow SK, et al. Pediatrics. 2022;150:e2022059673.

Children with emergent care needs are often cared for in complex situations that can diminish safety. This joint policy statement updates preceding recommendations to enhance the safety of care to children presenting at the emergency department. It expands on the application of topics within a high-reliability framework focusing on leadership, managerial factors, and organizational factors that support safety culture and workforce empowerment to support safe emergency care for children.

Notes on healing after a missed diagnosis.

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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.

Stakeholder safety communication: patient and family reports on safety risks in hospitals.

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Reader TW. J Risk Res. 2022;25:807-824.

Feedback from patients and other stakeholders can illuminate serious patient safety concerns. This qualitative study analyzed stakeholder feedback about patient safety risks as well as how organizations responded to stakeholder communication and discusses ways in which organizational risk management teams can leverage stakeholder feedback. Findings suggest that stakeholder communications have typically focused on safety issues such as medication errors, but that poor safety culture meant that concerns were often not acted upon.

Solutions from Professional Regulation and Beyond.

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Safer Care for All. London, England: Professional Standards Authority for Health and Social Care; 2022.

Dedicated leadership is an important component to examine and address challenges to safety across a system. This report outlines a process to reduce the complexity of care across the United Kingdom through the establishment of offices to address inequity, emerging risk regulation, workforce issues, accountability, and lack of trust in the system.

Fatal Solutions: How a Healthcare System Used Tragedy to Transform Itself and Redefine Just Culture.

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Davies JM, Steinke C, Flemons WW. New York, NY: Productivity Press; 2022. ISBN: 9781032028132.

Look-alike packaging can contribute to patient harm. This book examines how a mix up involving potassium chloride resulted in the deaths of two patients. The Canadian organization involved applied Reason’s strategies to work past blame to examine the events and consider how just culture can be entrenched organization-wide to improve safety for patients, families, and those who care for them.

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