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 494 Results

Assessing the impact of hospital mergers and acquisitions on safety culture with proactive risk assessments

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Folcarelli P, Hoffman J, Janes M, et al. J Healthc Risk Manag. 2023;Epub May 2.

Hospital mergers may improve some safety outcomes but also present challenges. This commentary describes how a third-party proactive risk assessment, ideally prior to the merger, can identify strengths and weaknesses of the organizations' safety cultures. The article describes an insurer-directed assessment, but other resources are also available, such as from the Institute for Healthcare Improvement National Action Plan.

Structural racism in behavioral health presentation and management.

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Rainer T, Lim JK, He Y, et al. Hosp Pediatr. 2023;13:461-470.

Structural racism and implicit biases can affect clinical judgement and impede the delivery of effective mental health care. Based on a case of an adolescent Black girl navigating through the pediatric behavioral health system, this article discusses how structural racism and health disparities in behavioral health care contributed to misdiagnosis and poor care. The authors outline several actions at the structural, institutional, and interpersonal levels to address racism’s impact on pediatric mental and behavioral healthcare.

Preventing Workplace Violence.

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National Action Alliance. June 27, 2023. 2:00- 3:00 PM (eastern)

Violence in the health care environment detracts from staff and clinician ability to provide safe care. Sponsored by the Centers for Disease Control and Prevention, this webinar will discuss the importance of violence prevention.

Adverse patient safety events during the COVID epidemic.

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Yackel EE, Knowles RS, Jones CM, et al. J Patient Saf. 2023;Epub May 1.

The COVID-19 pandemic dramatically changed healthcare delivery and exacerbated threats to patient safety. Using Veterans Health Administration (VHA) National Center for Patient Safety data, this retrospective study characterized patient safety events related to COVID-19 occurring between March 2020 and February 2021. Delays in care and exposure to COVID-19 were the most common events and confusion over procedures, missed care, and failure to identify COVID-positive patients before exposures were the most common contributing factors.

Lessons from the Covid War: An Investigative Report.

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Covid Crisis Group. New York: Public Affairs; 2023. ISBN‏: ‎9781541703803.

The transfer of failure experiences to generate learning and improve service is a complicated responsibility. This book examines breakdowns in the US response to the COVID-19 epidemic to understand causes of the problems, in order to better prepare health care, government, and public health systems for future pandemics. It also discusses what successes were achieved and how to capitalize on those improvements.

Laura Levis' death outside ER has changed hospital signage, lighting in Mass.

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Mullins L, Menard F. WBUR. April 27, 2023.

Incomplete information and building design problems can reduce access to care and contribute to harm. This story outlines how the state of Massachusetts responded to the accidental death of a patient unable to get help due to poor signage and incomplete directional information while experiencing an asthma attack.

Blood and blood products transfusion errors: what can we do to improve patient safety.

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Brown C, Brown M. Br J Nurs. 2023;32:326-332.

Incorrect patient registration, application of the wrong label, and blood draw from the wrong patient can all cause blood transfusion errors. This systematic review identified six studies related to nursing and blood transfusion safety. Errors fell into two broad categories - human and environmental factors, and education. Initial and continuing education for all members of the team, including registration staff, should be considered to improve and maintain transfusion safety.

Perceived discrimination in the community pharmacy: a cross-sectional, national survey of adults.

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Baffoe JO, Moczygemba LR, Brown CM. J Am Pharm Assoc (2003). 2023;63:518-528.

Minoritized and vulnerable people often experience delays in care due to systemic biases. This survey study examined the association between perceived discrimination at community pharmacies and foregoing or delaying picking up medications. Participants reported discrimination based on race, age, sexual orientation, ethnicity, income, and prescription insurance; those participants were more likely to delay picking up their medications. There was no association with discrimination and foregoing medications.

Burnout in Primary Care: Assessing and Addressing It in Your Practice.

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Gerteis J, Booker C, Brach C, et al. Rockville, MD: Agency for Healthcare Research and Quality; February 2023. AHRQ Publication No. 23-0025.

Burnout reduction in primary care is critical to patient safety. This resource is designed to help practices assess the causes of burnout in primary care and implement strategies to promote well-being. Suggested areas of focus include the reduction of documentation tasks, use of huddles and peer support.

Roadmap to Health Care Safety for Massachusetts.

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Massachusetts Healthcare Safety and Quality Consortium. Boston, MA: Betsy Lehman Center for Patient Safety; April 2023.

Collective engagement and focus are required to attain large system change. This plan centers on five goals to improve patient safety in Massachusetts: leadership and culture, operations and engagement, patient and family support, workforce wellbeing, and measurement and transparency. The document provides guidance for implementation of strategies targeting each goal to generate sustainable improvements.

The effect of documenting patient weight in kilograms on pediatric medication dosing errors in emergency medical services.

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Ward CE, Taylor M, Keeney C, et al. Prehosp Emerg Care. 2023;27:263-268.

Weight-based calculation errors and lack of weight documentation can lead to medication errors in pediatric patients. This analysis of Maryland emergency medical services (EMS) data including children who received a weight-based medication found that weight documentation was associated with a small but significantly lower rate of medication dose errors, particularly among infants and for epinephrine and fentanyl doses.

Delays in care during the COVID-19 pandemic in the Veterans Health Administration.

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Mills PD, Louis RP, Yackel E. J Healthc Qual. 2023;Epub Apr 11.

Changes in healthcare delivery due to the COVID-19 pandemic resulted in delays in care that can lead to patient harm. In this study using patient safety event data submitted to the VHA National Center of Patient Safety, researchers identified healthcare delays involving laboratory results, treatment and interventional procedures, and diagnosis.

Improving Diagnostic Safety and Quality

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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.

Preventable harm in the Canadian organ donation and transplantation system: a descriptive study of missed organ donor identification and referral.

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Zavalkoff S, O’Donnell S, Lalani J, et al. Can J Anaesth. 2023;Epub Mar 29.

Lack of timely identification and referral of potential organ donors and poor communication can lead to missed opportunities for life-saving organ transplants. This analysis of data from Canadian organ donation organizations estimates that there were 354 potentially missed transplants between 2016 and 2018.

Understanding complexity in a safety critical setting: a systems approach to medication administration.

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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.

Adopting high reliability organization principles to lead a large scale clinical transformation.

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Pozzobon LD, Lam J, Chimonides E, et al. Healthc Manage Forum. 2023;Epub Apr 6.

High-reliability organizations are able to achieve safety despite organizational changes or other hazardous conditions. This article describes the implementation of a new electronic health record (EHR) system at one academic health system in Canada and provides examples of how high-reliability principles informed activities to prevent patient harm during this organizational change.

Deficiencies in Emergent and Outpatient Care of a Patient with Alcohol Use Disorder at the Richard L. Roudebush VA Medical Center in Indianapolis, Indiana.

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Washington, DC: VA Office of the Inspector General; March 29, 2023. Report no. 21-03680-80.

Care systems for alcohol use disorder (AUD) patients are suboptimal. This report examines the case of a patient with AUD whose emergency care was mismanaged, uncoordinated, and incomplete, contributing to his death two days after discharge. The safety recommendations shared include improving discharge planning, assessment, and consideration of mental health conditions when caring for AUD patients.

Prevalence and causes of diagnostic errors in hospitalized patients under investigation for COVID-19.

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Auerbach AD, Astik GJ, O’Leary KJ, et al. J Gen Intern Med. 2023;Epub Mar 23.

COVID-19 ushered in new diagnostic challenges and changes in care practices. In this study conducted during the first wave of the pandemic, charts for hospitalized adult patients under investigation (PUI) for COVID-19 were reviewed for potential diagnostic error. Diagnostic errors were identified in 14% of cases; patients with and without diagnostic errors were statistically similar and errors were not associated with pandemic-related change practices.

Care Delivery within Community Mental Health Teams.

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

Patient suicide is a sentinel event. This report examines a suicide incident that identified problems with risk assessment and identification, family engagement, and medication management in the context of mental health provision when supporting patients in psychological distress.

Implement strategies to prevent persistent medication errors and hazards.

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ISMP Medication Safety Alert! Acute care edition. March 23, 2023;28(6):1-4.

Medication mistakes are recognized contributors to patient harm. This article discusses medication errors that continue to occur despite established practices that, if applied, can mitigate error occurrence. Recommended areas of focus include reducing emphasis on the “Five Rights” to address system problems, enhancing medication list accuracy, and improving neuromuscular blocking agent storage.

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