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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 1738 Results
Sutton E, Booth L, Ibrahim M, et al. Qual Health Res. 2022;32:2078-2089.
Patient engagement and encouragement to speak up about their care can promote patient safety. This qualitative study explored patients’ psychosocial experiences after surviving abdominal surgery complications. Findings highlight an overarching theme of vulnerability and how power imbalances between patients and healthcare professionals can influence speaking up behaviors.
Institute for Healthcare Improvement and British Medical Journal. Bella Center, Copenhagen, Denmark, May 15-17, 2023.
This onsite conference offers an introduction to quality and safety improvement success and challenges drawing from international experiences. Course activities designed for a multidisciplinary audience supporting the theme of "Adapting to a changing world: equity, sustainability and wellbeing for all" will cover topics such as healthcare inequality, workforce wellbeing, and adverse events as learning opportunities. 
Rodgers S, Taylor AC, Roberts SA, et al. PLoS Med. 2022;19:e1004133.
Previous research found that a pharmacist-led information technology intervention (PINCER) reduced dangerous prescribing (i.e., medication monitoring and drug-disease errors) among a subset of primary care practices in the United Kingdom (UK). This longitudinal analysis examined the impact of the PINCER intervention after implementation across a large proportion of general practices in one region in the UK. Researchers found the PINCER intervention decreased dangerous prescribing by 17% and 15% at 6-month and 12-month follow-ups, particularly among dangerous prescribing related to gastrointestinal bleeding.
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).
Sheikh A, Coleman JJ, Chuter A, et al. Programme Grants Appl Res. 2022;10:1-196.
Electronic prescribing (e-prescribing) is an established medication error reduction mechanism. This review analyzed experiences in the United Kingdom to understand strengths and weaknesses in e-prescribing. The work concluded that e-prescribing did improve safety in the UK and that the implementation and use of the system was a complex endeavor. The effort produced an accompanying toolkit to assist organizations in e-prescribing system decision making.
Hunt J, Gammon J, Williams S, et al. BMC Health Serv Res. 2022;22:1446.
Isolation for infection prevention and control may result in unintended consequences for patient safety. Using focus groups at two hospitals, this study explored healthcare staff understanding of infection prevention practices and patient safety culture within insolation settings. Thematic analysis highlights the importance of engaged leadership, appropriate staffing, teamwork, and prioritization of patient-centered care in achieving a culture of safety and improvements in infection prevention.
Rowland SP, Fitzgerald JE, Lungren M, et al. NPJ Digit Med. 2022;5:157.
The rapid expansion of digital health technologies, particularly in response to the COVID-19 pandemic, can increase patient safety risks. This article summarizes malpractice liability risks associated with digital health technologies, including electronic health record (EHR) systems, telehealth, and artificial intelligence for clinical decision support.
Darley S, Coulson T, Peek N, et al. J Med Internet Res. 2022;24:e37436.
Electronic communication between patients and clinicians has been increasing, with a rapid expansion of its use during the COVID-19 pandemic. This systematic review examined the types of online consultation available to patients in primary care and their impact on safety. Results reveal both positive and negative impacts, and the authors make recommendations to mitigate the negative impacts.
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.
Sutherland A, Jones MD, Howlett M, et al. Drug Saf. 2022;45:881-889.
Intravenous (IV) medication smart pumps can improve medication administration, but usability issues can compromise safety. This article outlines strategic recommendations regarding the implementation of smart pump technology to improve patient safety. Recommendations include standardization of infusion concentrations, improving drug libraries using a human-centered approach, and increasing stakeholder engagement.
Turner A, Morris R, McDonagh L, et al. Br J Gen Pract. 2022;73:e67-e74.
Patient access to electronic health records can improve engagement in care. This qualitative study involving patients and staff at general practices in the United Kingdom highlighted unintended consequences of online access to health records, including challenges with patient health literacy, decreased quality of documentation, and increases in staff workload.

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.
Adamson HK, Foster B, Clarke R, et al. J Patient Saf. 2022;18:e1096-e1101.
Computed tomography (CT) scans are important diagnostic tools but can present serious dangers from overexposure to radiation. Researchers reviewed 133 radiation incidents reported to one NHS trust from 2015-2018. Reported events included radiation incidents, near-miss incidents, and repeat scans. Most events were investigated using a systems approach, and staff were encouraged to report all types of incidents, including near misses, to foster a culture of safety and enable learning.
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.
Laing L, Salema N-E, Jeffries M, et al. PLoS ONE. 2022;17:e0275633.
Previous research found that the pharmacist-led IT-based intervention to reduce clinically important medication errors (PINCER) can reduce prescription and medication monitoring errors. This qualitative study explored patients’ perceived acceptability of the PINCER intervention in primary care. Overall perceptions were positive, but participants noted that PINCER acceptability can be improved through enhanced patient-pharmacist relationships, consistent delivery of PINCER-related care, and synchronization of medication reviews with prescription renewals.
Premier House, 60 Caversham Road, Reading, RG1 7EB.
Independent investigations examine system weaknesses in health care to inform improvement, reduce risk, and prevent harm. This organization collects information from individuals, groups, and organizations to identify and analyze incidents of substandard care and to proactively provide recommendations to reduce conditions that perpetuate failure in the National Health Service. Investigation areas include medication delivery for older patients and safe maternity care.
Newcastle Upon Tyne, UK: Care Quality Commission; October 2022.
This website provides access to an annual report that summarizes National Health Service hospital and social care performance across a range of care quality metrics at both the trust and service level. The 2022 report found most facilities to be generally operating at a effective level and basic performance was found to be high. However the report found substantial gaps in specialties such as maternity care and recognized staffing challenges that impact access and quality.

Dixon-Woods M, Martin G, eds. Cambridge, UK: Cambridge University Press; 2022.

Improvement activities are complex initiatives that require synergistic actions by organizations to be sustained. This evolving series provides background, evidence, and discussion on interdisciplinary strategies known to affect quality and safety such as implementation science, collaboration, positive deviance, and culture change.
Barrow E, Lear RA, Morbi A, et al. BMJ Qual Saf. 2022;Epub Oct 5.
Patient and family engagement in safety is a priority for the UK’s National Health Service. This study asked patients in three hospital wards (geriatrics, elective surgery, maternity) how they conceptualize patient safety. Responses described what made them “feel safe” in their experiences with the organization, staff, the patients themselves, and family/carers.