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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 2177 Results
Gilmartin HM, Saint S, Ratz D, et al. Infect Control Hosp Epidemiol. 2023;Epub Sep 13.
Burnout has been reported across numerous healthcare settings and disciplines during the COVID-19 pandemic. Among US hospital infection preventionists surveyed in this study, nearly half reported feeling burnt out, but strong leadership support was associated with lower rates of burnout. Leadership support was also associated with psychological safety and a stronger safety climate.

Amin D, Cosby K. Rockville, MD: Agency for Healthcare Research and Quality; September 2023. Publication No. 23-0040-6-EF.

Psychological safety to report errors stems from a robust safety culture. This issue brief examines how these two concepts intersect to enhance the self-reporting of diagnostic errors to facilitate organizational learning from mistakes.
Jones A, Neal A, Bailey S, et al. BMJ Lead. 2023;Epub Sep 10.
The well-being of healthcare workers is essential to the delivery of high quality, safe care. This article proposes a definition of “avoidable employee harm” (e.g., retaliation for speaking up about safety concerns) and describes how prioritizing organizational safety culture can increase both employee and patient safety.
Kirkup B, Titcombe J. BMJ. 2023;382:1972.
The latent nature of failure in health care is enabled by organizational inability or unwillingness to listen and respond to the concerns of patients, families, and clinicians. This commentary discusses a rare criminal event in the British National Health System (NHS) and the factors that allowed continued criminal activity to occur over time.
El Boghdady M, Ewalds-Kvist BM. Langenbecks Arch Surg. 2023;408:349.
Disruptive behavior in the healthcare setting can result in neglect of patient care, decreased teamwork, and poor safety culture. This study from the UK found that 22% of surgeons were at risk of displaying disruptive behavior in the workplace and that being bullied during surgical training predicted hostility. These results reinforce the need for strong safety culture and a supportive learning environment for trainees.
Amick AE, Schrepel C, Bann M, et al. Acad Med. 2023;98:1076-1082.
Disruptive behaviors, including experiencing or witnessing coworker conflict, can lead to staff burnout and adverse events. In this study, emergency medicine and internal medicine physicians reported on conflicts with other physicians they'd experienced in the workplace. Participants reported feeling demoralized and burnt out after a conflict and brought those feelings to future interactions, priming the situation for additional conflict.
Kane J, Munn L, Kane SF, et al. J Gen Intern Med. 2023;Epub Sept 5.
Clinicians and staff are encouraged to speak up about safety concerns as a part of patient safety culture. This review had two aims: to review the literature on speaking up for patient safety, and to develop a single definition of "speaking up" in healthcare. 294 articles were identified with 51 directly focused on speaking up and the remaining on other aspects such as communication. 11 distinct definitions were identified from which the authors developed a single definition: a healthcare professional identifying a concern that might impact patient safety and using his or her voice to raise the concern to someone with the power to address it.
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.
Seys D, Panella M, Russotto S, et al. BMC Health Serv Res. 2023;23:816.
Clinicians who are involved in a patient safety incident can experience psychological harm. This literature review of 104 studies identified five levels of support that can be provided to healthcare workers after a patient safety incident – (1) prevention, (2) self-care of individuals and/or teams, (3) support by peers and triage, (4) structured professional support, and (5) structured clinical support.
Institute for Safe Medication Practices. October 4-5, 2023, 10:45 AM - 7:45 PM (eastern).
This virtual workshop will explore tactics to ensure medication safety, including strategic planning, risk assessment, and Just Culture principles.
AMA J Ethics. 2023;25:E615-E623.
The safety culture of an operating room is known to affect teamwork and patient outcome. This article discusses the unique characteristics of robotic-assisted surgical practice and approaches teams and organizations can take to enhance communication that supports a safe care culture.
McCarthy SE, Hogan C, Jenkins L, et al. BMJ Open Qual. 2023;12:e002270.
Debriefing after significant clinical events helps affected staff develop a shared mental model of what happened, why it happened, and how it can be prevented in the future. This paper describes development of training videos on after action reviews (AAR)s, a type of debriefing. The videos introduce AAR, show a simulated AAR debriefing, offer techniques for handing challenging situations within an AAR, and reflections on the benefits. The videos are available with the online version of the paper.
Healthcare Excellence Canada.
This site provides promotional materials and registration information for an awareness campaign on patient safety that takes place in the autumn. The annual observance will take place October 23-27, 2023.
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.

WebM&M Case August 30, 2023

A 31-year-old pregnant patient with type 1 diabetes on an insulin pump was hospitalized for euglycemic diabetic ketoacidosis (DKA). She was treated for dehydration and vomiting, but not aggressively enough, and her metabolic acidosis worsened over several days. The primary team hesitated to prescribe medications safe in pregnancy and delayed reaching out to the Maternal Fetal Medicine (MFM) consultant, who made recommendations but did not ensure that the primary team received and understood the information.

Institute for Healthcare Improvement. Boston, MA and online. August 30-October 13, 2023.
Organization executives influence the success of patient safety improvement. This hybrid workshop will highlight how leaders can use assessments, planning, and evidence to improve the safety culture at their organizations.

Moritz J, Coffey J, Buchanan M. BBC News. August 19, 2023.

Whistleblowers can identify the presence of systemic failures, but the organization is responsible for acting on their reported concerns. This article summarizes the range of breakdowns that contributed to a British nurse serial murderer, who, despite warnings from others, continued to harm babies over several years.

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.
Kanaris C. J Child Health Care. 2023;27:319-322.
Hierarchy as an organizational or team structure is known to affect patient safety. This editorial examines the impact a strict chain of command can have on communication and awareness-raising actions in the care environment. The author illustrates how a staff’s ability to contribute to care goals and raise concerns is enhanced when all are respected as having valuable insights without deference to role or education level.
Institute for Healthcare Improvement.
This virtual fellowship program focuses on developing competencies for leading patient safety efforts. The deadline for submitting an application for the 2023–2024 class is October 16, 2023.