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 141 Results

System planning for modern-day Just Culture to mitigate worker distress and second victim response.

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Sells JR, Cole I, Dharmasukrit C, et al. BMJ Lead. 2023;Epub Sep 21.

Involvement in a patient safety event can result in serious psychological consequences for healthcare workers. This article describes the importance of proactive organizational planning to protect and support healthcare workers after involvement in a patient safety event and provides several examples of successful peer-support programs, such as the Resilience in Stressful Events (RISE) program or the Center for Professionalism and Peer Support.

Psychological safety as a new ACGME requirement: a comprehensive all-in-one guide to radiology residency programs.

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Mohamed I, Hom GL, Jiang S, et al. Acad Radiol. 2023;Epub Sep 22.

Psychological safety is an important principle in identifying problems and improving patient outcomes. This narrative review highlights five best practices to foster psychological safety in radiology residencies – (1) establish clear goals and educational strategies, (2) build a formal mentoring program, (3) assess psychological safety, (4) advocate for radiologists as educators, and (5) support non-radiology staff. Although the review focuses on radiology residency programs, these strategies can be adapted to any residency program.

Use of the Second Victim Experience and Support Tool (SVEST) to assess the impact of a departmental peer support program on anesthesia professionals' second victim experiences (SVEs) and perceptions of support two years after implementation.

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Pelikan M, Finney RE, Jacob A. AANA J. 2023;91(5):371-379.

Providers involved in patient safety incidents can experience adverse psychological and physiological outcomes, also referred to as second victim experiences (SVE). This study used the Second Victim Experience and Support Tool (SVEST) to evaluate the impact of a peer support program on anesthesia providers’ SVE. Two years after program implementation, reported psychological distress decreased and over 80% of participants expressed favorable views of the program and its impact on safety culture.

Supporting nurses in acute and emergency care settings to speak up.

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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.

React, reframe and engage. Establishing a receiver mindset for more effective safety negotiations.

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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.

Healthcare wants to fly as high as the aviation industry. Can it?

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Twenter P. Becker's Clinical Leadership. October 30, 2023.

Health care has long held commercial aviation as a beacon to guide patient safety improvement work. This article examines how well aviation safety mechanisms map to medical care safety efforts such as checklists, just culture and operating room black boxes.

Achieving a successful patient safety program with implementation of a harm reduction strategy.

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Cohen JB. APSF Newsletter. 2023;38(10):93-95.

Zero harm, while a laudable goal, has been shown to have unintended consequences. This commentary calls for a morally neutral approach to human error, an elimination of blame in favor of a just culture, and harm reduction efforts that target the system instead of the individual.

ISMP Medication Safety Intensive.

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Institute for Safe Medication Practices. November 30-December 1, 2023, 7:30 AM - 4:30 PM (eastern).

This virtual workshop will explore tactics to ensure medication safety, including strategic planning, risk assessment, and Just Culture principles.

Right Kind of Wrong: Why Learning to Fail can Teach us to Thrive.

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Edmondson A. Atria Books, New York, 2023. ISBN: 9781982195069.

Despite the harm that failure can cause, its value as a learning opportunity, if examined through the lens of human error rather than blame, cannot be understated. This book explores how failure that happens in new situations provides new insights toward goal achievement, utilizes knowledge and capitalizes on even small missteps, and can enhance and inform improvement.

Beyond the Pandemic: Creating Total Systems Safety

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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.

In Conversation with Patricia McGaffigan about Beyond the Pandemic: Creating Total Systems Safety

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 handoffs and multi-specialty trainee perspectives across an institution: informing recommendations for health systems and an expanded conceptual framework for handoffs.

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Williams SR, Sebok-Syer SS, Caretta-Weyer H, et al. BMC Med Educ. 2023;23:434.

Standardizing handoff training in residency programs can lead to safer, more effective handoffs. Researchers surveyed a sample of 687 residents and fellows from over 30 specialties about handoff training perspectives. Participants reported wide variability in handoff content and identified important aspects of handoff training (critical handoff elements, the impact of systems-level factors, impact of the handoff on providers and patients, professional duty, and addressing blame or guilt related to poor handoff experiences).

Amid lack of accountability for bias in maternity care, a California family seeks justice.

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Kwon S. KFF Health News. August 8, 2023

Implicit bias and systemic racism are known to affect the safety of Black maternal care. This story describes an incident of maternal death and the family’s effort to demonstrate the role of discrimination in the outcome and hold the clinicians and organization involved responsible.

Judy Smetzer Just Culture Champion Scholarships.

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Institute for Safe Medication Practices.

A Just Culture supports effective reporting and learning from mistakes. This scholarship, inspired by the work and leadership of Judy Smetzer, former editor of the ISMP Medication Safety Alert! newsletter, will support three team or individual certifications in Just Culture practice. The 2023 application process is now closed.

Improving Patient Safety Culture – A Practical Guide.

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London, UK: NHS England; July 2023.

A strong patient safety culture needs nurturing to serve as a foundation for launching and sustaining improvements. This toolkit provides access to existing tools that support teamwork and communication, fairness, psychological safety, promotion of diversity and inclusivity, and civility as elements of a safety culture.

Patient, carer and family experiences of seeking redress and reconciliation following a life-changing event: systematic review of qualitative evidence.

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Shaw L, Lawal HM, Briscoe S, et al. Health Expect. 2023;Epub Jul 14.

Patients who experience life-changing adverse events due to errors, and their families, typically want disclosure of the error and appropriate accountability. This systematic review identified 41 studies exploring the views of those affected by adverse events. Four themes were identified: transparency, person-centeredness, trustworthiness, and restorative justice. Applying these themes to investigations may result in ensuring the process and outcomes are experienced as "fair" to those impacted.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

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Patient Safety Innovation July 31, 2023

Concern over patient safety issues associated with inadequate tracking of test results has grown over the last decade, as it can lead to delays in the recognition of abnormal test results and the absence of a tracking system to ensure short-term patient follow-up.^1,2 Missed abnormal tests and the lack of necessary clinical follow-up can lead to a late diagnosis.

Building Capacity for Patient Safety

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Perspective on Safety July 31, 2023

This piece focuses on the importance of building the capacity of the workforce and organizations for patient safety using patient safety education.

In Conversation with Regina Hoffman about Building Capacity for Patient Safety

Emotional responses and support needs of healthcare professionals after adverse or traumatic experiences in healthcare-evidence from seminars on peer support.

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Schrøder K, Assing Hvidt E. Int J Environ Res Public Health. 2023;20:5749.

Healthcare providers may experience emotional distress after involvement in an adverse or traumatic event. This qualitative study with 198 healthcare professionals identified common emotions experienced after adverse events as well as the types of support needed after involvement in an adverse event. These findings can contribute to the development and refinement of support programs for healthcare workers after adverse events.

Systems approach to suicide prevention: strengthening culture, practice, and education.

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Pisani AR, Boudreaux ED. Focus (Am Psychiatr Publ). 2023;21:152-159.

Identifying patients with suicidal ideation can be a challenging clinical problem in the emergency department. These authors use a systems-based approach to identify missed opportunities to prevent suicide and present a systems approach to suicide prevention including three core domains – a culture of safety and prevention, applying best practices and policies for prevention in systems, and workforce education and development.

Requirements for implementing a 'just culture' within healthcare organisations: an integrative review.

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Murray JS, Lee J, Larson S, et al. BMJ Open Qual. 2023;12:e002237.

A “just culture” balances organizational responsibility and individual accountability after an error occurs. This integrative review of 16 articles identified four concepts critical to implementing a “just culture” in healthcare settings – leadership commitment, education and training, accountability, and open communication.

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