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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 2021 Results
Staal J, Zegers R, Caljouw-Vos J, et al. Diagnosis (Berl). 2022;10:121-129.
Checklists are increasingly used to support clinical and diagnostic reasoning processes. This study examined the impact of a checklist on electrocardiogram interpretation in 42 first-year general practice residents. Findings indicate that the checklist reduced the time to diagnosis but did not affect accuracy or confidence.
Gefter WB, Hatabu H. Chest. 2023;163:634-649.
Cognitive bias, fatigue, and shift work can increase diagnostic errors in radiology. This commentary recommends strategies to reduce these errors in diagnostic chest radiography, including checklists and improved technology (e.g., software, artificial intelligence). In addition, the authors offer practical step-by-step recommendations and a sample checklist to assist radiologists in avoiding diagnostic errors.

ISMP Patient Safety Alert! Acute care edition. May 18, 2023;28(10);1-3.

Dose error-reduction systems (DERS) and drug libraries are tools for use with smart infusion pumps to ensure safe intravenous medication administration. This article discusses infusion problems unrelated to user error that went undetected by the technology and reached patients. Recommendations to minimize similar occurrences include removing the involved device from service and investigating the incident.
Pati AB, Mishra TS, Chappity P, et al. Jt Comm J Qual Patient Saf. 2023;Epub Apr 22.
The World Health Organization (WHO) Surgical Safety Checklist is widely used, but implementation challenges remain. This article describes the development of an electronic version of the surgical safety checklist adapted for use on a personal device, and compared its use against the traditional paper-based checklist. The electronic checklist had 100% use (compared to 98% for the traditional checklist) and significantly higher frequency of completion (100% vs. 27%).

Moyal-Smith R, Margo J, Maloney FL, et al. J Patient Saf. 2023;19(4):243-248.

Individual, team, and organizational challenges can hinder the effective implementation of patient safety initiatives. This article describes the development of the Patient Safety Adoption Framework, which includes five domains supporting the adoption and implementation of patient safety initiatives (leadership, culture and context, process, meaningful measurement, and person-centeredness).
Pugh S, Chan F, Han S, et al. J Nurs Adm. 2023;53:292-298.
The COVID-19 pandemic dramatically impacted the delivery of nursing care. This retrospective analysis examined the impact of a bedside checklist and nursing-led intervention bundle (“Nursing Back to Basics” or NB2B bundle) among patients hospitalized with COVID-19 at one academic hospital in New York City. The NB2B bundle, implemented with a bedside checklist, included five evidence-based interventions. Between March and April 2020, the NB2B intervention showed a 12% reduction in mortality due to COVID-19 compared with usual care.

Epsom and St Helier University Hospitals. Epsom, UK: National Health Service; March 21, 2023.

The Systems Engineering Initiative for Patient Safety (SEIPS) framework is an established human factors-based approach to designing care system improvements. This video introduces the concepts behind SEIPS and uses an everyday non-clinical activity to illustrate its use for a broad audience to identify problems.
Machen S. BMJ Open Qual. 2023;12:e002020.
Learning from patient safety incidents can help health care organizations improve processes and care delivery. This article provides a template for organizations to review patient safety incidents and classify them into themes from a human factors and systems thinking perspective. The process involves clearly characterizing the safety incidents, describing the involved safety systems, identifying and classifying contributing factors, completion of narrative analysis to identify commonalities and differences in the way contributing factors affect the incidents, and identification of safety recommendations. 
Moran JM, Bazan JG, Dawes SL, et al. Pract Radiat Oncol. 2023;13:203-216.
Safety risks are present in oncology radiation therapy. This recommendation builds on existing intensity modulated radiation therapy (IMRT) standards to highlight the importance of interdisciplinary engagement, training, and technology implementation to ensure high quality, safe IMRT is delivered to patients.
Awad S, Amon K, Baillie A, et al. Int J Med Inform. 2023;172:105017.
Computerized provider order entry (CPOE), clinical decision support (CDS), and electronic medication management systems (EMMS) have increased efficiency and reduced prescribing errors, but poor design may introduce new safety hazards. Human factors and safety analysis methods can be used to increase the safety of new technologies, ideally before problems arise. This review identifies human factors and safety analysis methods applied to EMMS. Most methods focused on usability or design, and only one used a safety-oriented approach. Increased inclusion of human factors specialists could increase the use of safety-oriented methods of EMMS design.
May 4, 2023
The implementation of effective patient safety initiatives is challenging due to the complexity of the health care environment. This curated library shares resources summarizing overarching ideas and strategies that can aid in successful program execution, establishment, and sustainability.

Clinical Human Factors Group. May 16, 2023, 9:00 AM--12:30 PM (eastern).

Organizations and individuals learn by considering how humans interact while performing routine tasks. This seminar will examine the opportunities for improvement in examining what work-as-done efforts reveal, embedding human factors design considerations into daily work processes, and prioritizing front-line staff experience as a component of safety.
Lyell D, Wang Y, Coiera E, et al. J Am Med Inform Assoc. 2023;Epub Apr 18.
Patients and healthcare providers rely on devices that use artificial intelligence or machine learning in diagnostics, treatment, and monitoring. This study utilizes adverse event reports submitted to the FDA's Manufacturer and Use Facility Device Experience (MAUDE) database for machine learning-enabled devices. Mammography was implicated in 69% of reports, and the majority were near-miss events.
Larimer C, Sumner V, Wander D. Nutr Clin Pract. 2023;Epub Apr 19.
Medical lines, such as intravenous (IV), oxygen, or feeding tubes, provide lifesaving support but may also pose safety threats. Following a 2022 Food and Drug Administration safety communication regarding risk of strangulation by feeding tubes, researchers sought to determine if pediatric healthcare providers and caregivers were aware of the risk of medical line entanglement, and what, if any, type of education was provided to reduce the risk. Most providers were aware of the risk of entanglement, and 90% of caregivers reported their child had become entangled. However, less than 10% of caregivers received training to prevent such entanglements. Numerous comments from caregivers are provided, describing instances of entanglements and strategies they’ve used to prevent it.
Perspective on Safety April 26, 2023

Throughout 2022, AHRQ PSNet has shared research that elucidates the complex nature of misdiagnosis and diagnostic safety. This Year in Review explores recent work in diagnostic safety and ways that greater safety may be promoted using tools developed to improve diagnostic practices.

Throughout 2022, AHRQ PSNet has shared research that elucidates the complex nature of misdiagnosis and diagnostic safety. This Year in Review explores recent work in diagnostic safety and ways that greater safety may be promoted using tools developed to improve diagnostic practices.

Perspective on Safety April 26, 2023

This piece discusses surveillance monitoring of patients in low-acuity units of the hospital to prevent failure to rescue events, its difference from high-acuity continuous monitoring, and its potential applications in other settings.

This piece discusses surveillance monitoring of patients in low-acuity units of the hospital to prevent failure to rescue events, its difference from high-acuity continuous monitoring, and its potential applications in other settings.

Drs. Susan McGrath and George Blike discuss surveillance monitoring and its challenges and opportunities.

Farnborough, UK: Healthcare Safety Investigation Branch. March 2023.

Patients receiving hemodialysis are at risk of complications, including air embolus. This report describes how unfamiliar equipment and lack of standardized training contributed to the death of a dialysis patient due to air embolus. Safety recommendations include changes in medical education on how to handle uncertainty in clinical settings and amending dialysis guidelines to include risk of air embolus associated with unclamped central venous catheters.
Stevens EL, Hulme A, Goode N, et al. Appl Ergon. 2023;110:104000.
Medication administration is a complex process with many opportunities for error. Using the Event Analysis of Systemic Teamwork (EAST) model, researchers identified opportunities to improve medication administration system performance and promote patient safety. The authors discuss the networks involved in medication administration (e.g., task network, social network, information network) and how the complexities involved in each network contribute to medication administration errors.
Duffy C, Menon N, Horak D, et al. JAMA Netw Open. 2023;6:e237621.
Safety-II is a proactive approach to improving patient safety by focusing on what goes right in healthcare. This study describes the use of a novel tool and activity, One Safe Act (OSA), to capture activities performed by perioperative staff that keep patients safe. Eight themes emerged, with the most common theme being routines the staff “always” performed, followed by confirming resource availability.