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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 3511 Results
Institute for Safe Medication Practices.
The Institute for Safe Medication Practices sponsors the annual Cheers Awards to recognize both individuals and institutions for their commitment to medication safety. The 2023 awards recognized Susan Donnell Scott PhD for her work focusing on support mechanisms for clinicians involved in medical error.
Winter SG, Sedgwick C, Wallace-Lacey A, et al. Clin Ther. 2023;45:928-934.
The VIONE (Vital, Important, Optional, Not indicated, and Every medication has an indication) tool is used to reduce polypharmacy and potentially inappropriate prescribing. This article provides an overview of VIONE implementation and dashboards used to track VIONE implementation and its impact on prescribing across over 130 Veterans Health Administration medical centers. Since implementation in 2016, VIONE has led to the discontinuation of over 1.6 million medication orders by more than 15,000 providers.

ISMP Medication Safety Alert! Acute Care. November 2, 2023;28(22):1-4.

Intravenous (IV) push medication administration is a primary therapeutic approach where process gaps can result in harm. This article examines existent presence of recognized safe practice education in close to 200 surveyed nursing programs to assess the teaching of standardized practice behaviors at the student level and recommend strategies to embed IV safety into instruction efforts.

National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2023. ISBN: 9780309711937.

Maternal health care is rapidly emerging as a high-risk service that is vulnerable to communication, equity, and diagnostic challenges. This report examines the role of disparities in care across the maternal care continuum and strategies to drive diagnostic improvement such as care bundles, midwives, and health information technology. This publication is from a series of programs and resultant publications on improving diagnostic excellence.
Liu Y, Jun H, Becker A, et al. J Prev Alz Dis. 2023;Epub Oct 24.
Persons with dementia are at increased risk for adverse events compared to those without dementia, highlighting the importance of a timely diagnosis. In this study, researchers estimate approximately 20% of primary care patients aged 65 and older are expected to have a diagnosis of mild cognitive impairment or dementia; however, only 8% have received such a diagnosis. Missed diagnosis prevents patients from receiving appropriate care, including newly FDA-approved medications to slow cognitive decline.
Lim PJH, Chen L, Siow S, et al. Int J Qual Health Care. 2023;35:mzad086.
Surgical safety checklists (SCC) are utilized around the world, but checklist completion at the operating room level remains inconsistent. This review summarizes facilitators and barriers to completion. Resistance or endorsement at the individual surgeon level remains a significant factor in SSC completion. Early inclusion of frontline staff in evaluation and implementation supported increased use.
Clarke-Romain B. Emerg Nurse. 2023;Epub Sep 19.
Delays in raising concerns in acute or emergency care can have tragic consequences. This commentary uses a case study to highlight barriers to speaking up and evidence-based tools nurses can use such as the CUS Tool and two-challenge rule. Training all healthcare staff in communication techniques can encourage speaking up and respectful responses.
Barlow M, Watson B, Morse K, et al. J Health Organ Manag. 2023;Epub Sep 26.
Hierarchy and expected response may inhibit someone from speaking up about a safety concern. This study used two vignettes of a speaking up situation with randomization on speaker seniority, discipline (i.e., allied staff, nurse, physician), tone (i.e., accommodating or non-accommodating), and the presence of other people in the room. All participants were more likely to respond positively to the accommodating tone, but the impact of seniority varied by receiver's discipline.
Baker DL, Giuliano KK, Desmarais M, et al. Infect Control Hosp Epidemiol. 2023;Epub Oct 25.
Hospital-acquired pneumonia (HAP) is one of the most common healthcare-associated infections in the United States. In this case-control retrospective study of Medicare beneficiaries, patients with HAP were 2.8 times more likely to die than patients without HAP. Length of stay and overall cost were also significantly higher in the HAP group. The authors suggest quality improvement efforts like the Keystone ICU project could decrease HAP rates, saving lives and money.
Bagot KL, McInnes E, Mannion R, et al. BMC Health Serv Res. 2023;23:1012.
Unprofessional behavior can have a detrimental effect on coworkers, culture, and patient safety. This qualitative study presents perspectives of middle managers in hospitals that implemented a program allowing and encouraging workers to report unprofessional, as well as positive, behavior. Themes included staying silent but active (e.g., avoiding the unprofessional colleague), history and hierarchy, and double-edged swords (e.g., pros and cons of anonymous reporting).

Rockville, MD: Agency for Healthcare Research and Quality: November 2023.

Patient safety progress is dynamic, consistently producing evidence for application to generate improvements. This report is the fourth in a series funded by the Agency for Healthcare Research and Quality to track a prioritized set of emerging and existing safety approaches to confirm their value and effectiveness. This report will be compiled as new conclusions are formulated. Each review will be posted to the collection as they are completed. The first three Making Healthcare Safer reports, published in 2001, 2013, and 2020, have each served as a consolidated evidence source for clinicians, health system leadership, researchers, and government agencies. Chapter protocols and the results of an examination on patient and family engagement and report cards as a surgical improvement mechanism are now available. 
Terwilliger IA, Johnson JK, Manojlovich M, et al. Jt Comm J Qual Patient Saf. 2023;Epub Sep 4.
Quality improvement and patient safety initiatives are difficult to implement and sustain. This commentary describes factors that contributed to successful implementation of the REdesigning SystEms to Improve Teamwork and Quality for Hospitalized Patients (RESET) study. Consistent with other research, important factors included leadership involvement, goal alignment, site leader commitment, and nurse/physician agreement that improvement was needed. The authors suggest hospital leaders consider these contextual factors prior to implementing similar improvement projects.
Dorimain M-V, Plouffe-Malette M, Paquette M, et al. BMJ Open Qual. 2023;12:e002291.
Laboratory tests are an integral part of diagnosing illness and injury, but system issues can result in the delayed communication of results to patients. This article describes use of the AHRQ toolkit Improving Your Office Testing Process to implement new testing and communication procedures. As an academic family practice clinic, an important first step was allowing residents to order tests and receive results in their own name instead of through an attending physician, which can cause delays in communication to patients. Providers and patients were satisfied with the new process.
Carvalho REFL de, Bates DW, Syrowatka A, et al. BMJ Open Qual. 2023;12:e002310.
Research has shown a robust safety culture improves patient outcomes, reduces length of hospital stay, and increases patient and staff satisfaction. As such, safety culture is increasingly being measured by healthcare organizations. This review sought to identify the factors measured by safety culture instruments in hospitals. The Hospital Survey on Patient Safety Culture and Safety Attitudes Questionnaire were the most frequently used instruments. Important factors include organizational, professional, and patient and family participation, although none of the instruments measured all three.
Lea W, Lawton R, Vincent CA, et al. J Patient Saf. 2023;19:553-563.
Organizational incident reporting allows for investigation of contributing factors and formation of improvement recommendations, but some recommendations are weak (e.g., staff training) and do not result in system change. This review found 4,579 recommendations from 11 studies, with less than 7% classified as "strong". There was little explanation for how the recommendations were generated or if they resulted in improvements in safety or quality of care. The authors contend additional research into how recommendations are generated and if they result in sustained improvement is needed.
The Joint Commission.
The National Patient Safety Goals (NPSGs) are one of the major methods by which The Joint Commission establishes standards for ensuring patient safety in all health care settings. In order to ensure health care facilities focus on preventing major sources of patient harm, The Joint Commission regularly revises the NPSGs based on their impact, cost, and effectiveness. Major focus areas include promoting surgical safety, achieving health equity, and preventing hospital-acquired infections, medication errors, inpatient suicide, and specific clinical harms such as falls and pressure ulcers. The 2024 goals are now available.
Okemos, MI: Michigan Health & Hospital Association.
This publication annually reports on the successful outcomes of the Michigan Keystone Center collaborative activities. The achievements noted in the 2022-2023 data review include reduction of MHA Keystone Center PSO members have significantly reduced both fall and blood or blood product events reported to the state patient safety organization reporting system. Areas of focus for improvement work reported on include health equity, workforce wellbeing, and maternal health.
Shaikh U, Kim JM, Yin SH. Clin Pediatr (Phila). 2023;20:6788.
The American Academy of Pediatrics' Policy Statement, "Preventing Home Medication Administration Errors", called for improving medication safety at home for children with medical complexity. This article describes a toolkit for pediatricians to support implementation focusing on four interventions: establishing practice-based error reporting systems, standardizing medication reconciliation, improving communication, and integrating resources for patients and families. Of particular importance is the use of health literacy-informed, culturally sensitive resources.
Congenie K, Bartjen L, Gutierrez D, et al. Jt Comm J Qual Patient Saf. 2023;Epub Aug 27.
Simulations are routinely used to identify latent safety threats. This article describes the classification of 1,318 latent safety threats identified from 232 simulations. Researchers were then able to issue site-specific and organization-wide standardized dashboards and summaries, thus allowing for local and systemwide improvements.