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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 5185 Results

World Health Organization.

The sharing of best practices is a key component of enabling successful strategy implementation in support of patient safety plans and goals. This website will capture, organize, and share experiences worldwide to support knowledge sharing and community building to reduce World Patient Safety Day targeted challenges.

Peterson M. Los Angeles Times. September 5, 2023.

Safe practice in community pharmacy is challenged by production pressure, workforce shortages, and multitasking. This story examined the mistakes made at major retail pharmacy chains in California. It provides examples perpetrated across the industry to target universal areas of needed improvement and potential strategies to address them.

Rockville, MD: Agency for Healthcare Research and Quality: September 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 of harms associated with video-based telehealth are now available. 
Wallin A, Ringdal M, Ahlberg K, et al. Scand J Caring Sci. 2023;37:414-423.
Numerous factors can hinder safe radiology practices, such as communication failures and image interpretation errors. Based on semi-structured interviews with 17 radiologists in Sweden, this study identified 20 themes at the individual-, organization-, technology-, task-and environment-levels describing factors supporting patient safety in radiology. Factors described by participants included the use of standardized tools and work routines (e.g., checklists), handoffs, and incident reporting systems.

Zucchelli G, Stefanini M, eds. Periodontol 2000. 2023;92(1):1-398.

Patient safety in dentistry shares common challenges with medicine and their emergence in a distinct care environment. This special issue covers a range of adverse events and treatment mistakes associated with periodontal procedures. Topics examined include human factors, implant placement and methodologic bias.
Stærk M, Lauridsen KG, Johnsen J, et al. Resusc Plus. 2023;14:100410.
In situ simulation is a valuable tool to identify latent safety threats. In this study, 36 unannounced in situ in-hospital cardiac arrest (IHCA) simulations were conducted across 4 hospitals and identified 30 system errors. Errors were categorized as involving human, organization, hardware, or software errors. These system errors contributed to treatment delays and care omissions.

Grubenhoff JA, Cifra CL, Marshall T, et al. Rockville, MD: Agency for Healthcare Research and Quality; September 2023. AHRQ Publication No. 23-0040-5-EF.

Unique challenges accompany efforts to study and reduce diagnostic error in children. This issue brief discusses addressing obstacles associated with testing and care access limitations that affect diagnosis across a variety of pediatric care environments. It also provides recommendations for building capacity to advance pediatric diagnostic safety. This issue brief is part of a series on diagnostic safety.
Griffeth EM, Gajic O, Schueler N, et al. J Patient Saf. 2023;19:422-428.
Voluntary reporting is an important tool for institutions to identify latent safety threats before they reach the patient but barriers to reporting result in low reporting rates. This quality improvement (QI) project aimed to increase near miss and error reporting within 9 intensive care units (ICU) in one healthcare system. After identifying barriers to reporting (e.g., user difficulty with online reporting system), a multi-faceted intervention was developed and implemented. Error reporting increased in 6 of 9 ICUs following implementation, with a significant increase in near miss reports.
de Dios JG, Lopez-Pineda A, Juan GM-P, et al. BMC Pediatr. 2023;23:380.
Children are at-risk for medication errors in the home setting, but no single database exists to collect these errors. This study compared parent and pediatrician perspectives on home medication safety for children aged 14 and under. Approximately 80% of pediatricians thought parents consulted the internet for information about their child's care and medications, and an equal percent of parents reported consulting their healthcare provider. Both groups reported lack of parental knowledge as the main contributor to medication errors, and most pediatricians supported the idea of a mechanism for collecting parent-reported errors and a learning system to support family engagement in medication error prevention.

Stratford, London; The National Guardian.

Organizational efforts to collect and respond to the concerns of staff and patients are a cornerstone to patient safety improvement despite challenges to implement them. This annual report presents insights drawn from problems staff share with Freedom to Speak Up Guardians in the United Kingdom to capitalize on problems to drive improvement. The 2023 report summarized data collected from over 25,000 cases recorded.
Mauskar S, Ngo T, Haskell H, et al. J Hosp Med. 2023;18:777-786.
Parents of children with medical complexity can offer unique perspectives on hospital quality and safety. Prior to their child's discharge, parents were surveyed about their child's care, medications, safety, and other concerns experienced during their stay. Parents reported experiencing miscommunication with the providers and providers seemingly not communicating with each other. They also reported inconsistency in care/care plans, unmet expectations, lack of transparency, and a desire for their expertise to be taken seriously.
Perspective on Safety August 30, 2023

This piece focuses on the importance of patient safety following the end of the public health emergency and how organizations can move beyond the pandemic.

This piece focuses on the importance of patient safety following the end of the public health emergency and how organizations can move beyond the pandemic.

Patricia McGaffigan

This piece focuses on the importance of patient safety following the end of the public health emergency and how organizations can move beyond the pandemic.

Patient Safety Innovation August 30, 2023

Addressing diagnostic errors to improve outcomes and patient safety has long been a problem in the US healthcare system.1 Many methods of reducing diagnostic error focus on individual factors and single cases, instead of focusing on the contribution of system factors or looking at diagnostic errors across a disease or clinical condition. Instead of addressing individual cases, KP sought to improve the disease diagnosis process and systems. The goal was to address the systemic root cause issues in systems that lead to diagnostic errors.

Tabaie A, Sengupta S, Pruitt ZM, et al. BMJ Health Care Inform. 2023;30(1):e100731.

Analyzing patient safety incident reports is essential to organizational learning, but comes with both a time and financial burden. This study found that natural language processing can be used to process unstructured patient safety event reports and reduce the burden of manually identifying and extracting factors contributing to the event.

CAHPS Research Meetings. Agency for Healthcare Research and Quality, Rockville, MD. October 19, 2023; 11:00 AM—4:00 PM (eastern).

Patient narrative is an important resource for understanding care delivery. This webinar will discuss how Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys can provide patient experience insights that could inform safety culture improvement efforts and lower risks stemming from poor patient/team communication.
Paull DE, Newton RC, Tess AV, et al. J Patient Saf. 2023;19:484-492.
Previous research suggests that residents may underutilize adverse event reporting tools. This article describes an 18-month clinical learning collaborative among 16 sites intended to increase resident and fellow participation in patient safety event investigations. Researchers found the collaborative increased participation in event investigation and improved the quality of the investigation.
Hooftman J, Dijkstra AC, Suurmeijer I, et al. BMJ Qual Saf. 2023;Epub Aug 9.
Diagnostic errors are common and have many contributing factors. This study analyzed more than 100 serious adverse event (SAE) reports in acute care using four investigation methods (e.g., Diagnostic Error Evaluation Research (DEER) taxonomy, Safer Dx Instrument) to identify common contributing factors. Transitions of care were particularly vulnerable to SAE, often due to incomplete communication between departments. Diagnostic errors occurred most often in the testing, assessment, and follow-up phases, with human factors as the most common contributing factor. Using multiple investigative methods supports more targeted interventions in each phase of diagnosis.

Washington, DC: United States Government Accounting Office; July 10, 2023.  Publication GAO-23-105722.

Health information systems are fundamental tools for documenting adverse event trends within and across patient populations. This report highlights weaknesses in the web-based incident reporting system employed to track quality of care for American Indians and Alaska Natives. Recommendations for improvement focus on increasing leadership engagement and use of the data collected to examine instances of patient harm or near misses in the American Indians and Alaska Native patient population.
Axelsen MS, Baumgarten M, Egholm CL, et al. J Adv Nurs. 2023;Epub Jun 30.
Rapid response teams (RRT) are activated, typically by nurses, when a patient demonstrates signs of imminent clinical deterioration, in order to prevent death or transfer to the intensive care unit (ICU). This study asks ICU managers about their perceptions of RRT beyond the stated goal of preventing patient deterioration. They describe the RRT as providing valuable education for new nurses and physicians and enhancing cohesion between the ICU and other wards. However, nurse managers stated they wanted more data and feedback from executive leadership.
Koppel R, Kuziemsky C, Elkin PL, et al. Stud Health Technol Inform. 2023;304:21-25.
Health information technology (HIT) has improved many aspects of patient safety, but poor design can result in patient harm. This commentary describes how context influences vendor, organization, and user understanding of HIT-related errors and proposes system-level solutions, in particular a focus on user-centered design.