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 209 Results

Safety Management Systems - an Introduction for Healthcare.

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Dorset, UK: Health Services Safety Investigations Body; October 2023.

Safety management systems (SMS) are employed in many high-risk industries, yet are not fully adopted in health care. This investigation report discusses the core safety elements of an SMS (policy, risk management, assurance, and promotion), how they are defined in a wide range of industries, and how they might be systemically embedded in the care environment to support safety culture, accountability, and maturity.

Authentic leadership at the Cleveland Clinic: psychological safety in the midst of crisis.

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Porter TH, Peck JA, Bolwell B, et al. BMJ Lead. 2023;7:196-202.

Authentic leadership principles emphasize the influence of positive psychological capacities to foster self-awareness and self-regulated positive behaviors. This qualitative study used podcast transcripts to explore the experiences of senior leadership during the COVID-19 pandemic and the role of authentic leadership principles. The researchers identified several behaviors demonstrating authentic leadership and discuss its influence of psychological safety, particularly during a crisis.

Addressing Workplace Violence and Creating a Safer Workplace

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Perspective on Safety October 31, 2023

This piece focuses on workplace violence trends in healthcare settings and strategies for creating a safer healthcare environment.

In Conversation with Cheryl Jones about Addressing Workplace Violence and Creating a Safer Workplace

Editor’s note: Cheryl B. Jones is a professor, director of the Hillman Scholars Program, and interim associate dean of the School of Nursing’s PhD program at the University of North Carolina at Chapel Hill. We spoke to her about workplace violence trends in healthcare settings and how we can create a safer work environment for healthcare staff.

California pharmacies are making millions of mistakes. They’re fighting to keep that secret.

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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.

How Columbia ignored women, undermined prosecutors and protected a predator for more than 20 years.

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Fortis B, Bell L. Pro Publica. September 12, 2023.

Sexual abuse of a patient is a never event. This article discusses how criminal behavior remained latent at a large health system due to persistent disregard of patient concerns, which enabled a serial sexual abuser to continue to practice medicine. The harm to the victims and fear of the peers who knew of the situation and were not psychologically safe enough to report it, are discussed.

Annual Speak Up Data Reports.

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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.

In their own words: safety and quality perspectives from families of hospitalized children with medical complexity.

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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.

Hospital bosses ignored months of doctors' warnings about Lucy Letby.

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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.

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.

Deficiencies in Emergency Department Care for a Patient Who Died by Suicide at the John Cochran Division of the VA St. Louis Health Care System in Missouri.

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Washington DC: Department of Veterans Affairs, Office of Inspector General; June 29, 2023. Report no. 22-01540-146.

This report analyzed a patient suicide at an emergency department and determined factors in the delay of care that contributed to patient harm. This report shares recommendations to address leadership failures and other deficiencies including poor screening and patient monitoring. Post-event gaps identified include poor root cause analysis, disclosure, and reporting activities.

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.

Quality of Care Concerns and the Facility Response Following a Medical Emergency at the VA Southern Nevada Health Care System in Las Vegas.

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Washington, DC: VA Office of the Inspector General; June 28, 2023. Report no. 22-02725-132.

Delays in emergency care provision can contribute to patient harm. This analysis examined an instance of cardiopulmonary resuscitation (CPR) delay and the poor response once the emergency was identified at an outpatient clinic. System-level issues flagged include incomplete incident records and follow up. Staff training, emergency notification, CPR process compliance, and debrief results completion were among the recommendations for improvement.

Broken Trust: Making Patient Safety More than Just a Promise.

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Manchester, UK: Parliamentary and Health Service Ombudsman; June 2023. ISBN: 9781528642446.

Lack of accountability for systemic contributions to failure degrades efforts to generate improvement. This report discusses gaps in the British National Health Service patient safety culture. It calls for governmental oversight and commitment as the central activation lever necessary to achieve collective, coordinated effort and motivate large-scale action to support lasting change.

Patient safety 2.0: slaying dragons, not just investigating them.

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Card AJ. J Patient Saf. 2023;19:394-395.

A full cycle of examination, planning, and strategic implementation is required to improve safety through system change. This commentary explores reasons for the persistent overemphasis on patient safety incident tabulation and analysis in lieu of the employment of actions that serve to reduce the potential for accident occurrence.

Disclosing medical errors: prioritising the needs of patients and families.

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Gallagher TH, Hemmelgarn C, Benjamin EM. BMJ Qual Saf. 2023;32:557-561.

Numerous organizations promote communication with patients and families after harm has occurred due to medical error. This commentary reflects on perceived barriers to patient disclosure and describes the patient and family perspectives and needs following harm. The authors promote the use of Communication and Resolution Programs (CRP) such as the learning community Pathway to Accountability, Compassion, and Transparency (PACT) to advance research, policy, and transparency regarding patient harm.

Inside the preventable deaths that happened within a prominent transplant center.

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Blau M. ProPublica. June 14, 2023.

Medical errors during organ transplants can have catastrophic consequences. This report describes the errors that contributed to failed transplants and patient deaths at one liver transplant center and the organizational-level factors that allowed these errors to continue for several years.

'Speaking Up' for patient safety and staff well-being: a qualitative study.

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Delpino R, Lees-Deutsch L, Solanki B. BMJ Open Qual. 2023;12:e002047.

Following the 2013 release of the Report of The Mid Staffordshire NHS Foundation Trust inquiry, National Health Service (NHS) Trusts have made substantial efforts to increase staffs’ willingness to speak up about patient safety concerns. One method is the creation of confidential resources who provide staff support: Freedom to Speak Up Guardians (FTSUG) and Confidential Contacts (CC). This study explored perspectives of FTSUG and CC on how they best support staff and how leaders can encourage speaking up behavior.

Medical errors kill thousands of people each year. But are hospitals getting any safer?

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Weintraub K. USA Today. May 3, 2023.

The semi-annual Leapfrog Hospital Safety Grades are recognized across the industry as a tool for highlighting successes and tracking gaps in safety to focus improvement efforts. This article shares one organization’s work to improve core safety activities related to medication safety, falls, infections, and hand hygiene.

Comparing perspectives on organisational silence: an analysis of the Gosport inquiry.

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Powell M. J Health Org Manag. 2023;37(1):67-83.

Individual, team, and organizational willingness to identify and address safety problems is an important indicator of safety culture. The authors of this article apply ten perspectives on organizational silence to understand the organizational failures contributing to dangerous opioid prescribing practices at Gosport Hospital.

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.

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