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 192 Results

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.

Barriers and facilitators to improving patient safety learning systems: a systematic review of qualitative studies and meta-synthesis.

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Mahmoud HA, Thavorn K, Mulpuru S, et al. BMJ Open Qual. 2023;12:e002134.

Incident reporting systems offer important opportunities for health systems to learn from safety events and improve outcomes. This systematic review of 22 studies identified barriers and facilitators influencing how health systems use and learn from incident reporting systems. Barriers included inadequate organizational support and resources, weak safety culture, lack of training and feedback, and a punitive environment. Factors supporting continuous improvement based on incident reporting systems included continuous training for staff, a just culture, leadership investment, and tangible improvements stemming from incident analysis.

Listening, Learning, Responding to Concerns.

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Newcastle Upon Tyne, UK: Care Quality Commission; March 2023.

The ability to raise patient safety concerns without fear of retribution is a core element of a safety culture. This pair of reports examines a failure in organizational response to an employee expressing concerns. The first report examines an explicit whistleblowing incident in the National Health Service that was poorly managed. The second looks at broader system-level elements needed to support effective responses when concerns are voiced.

Creating a stronger culture of safety within US community pharmacies.

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Lewis NJW, Marwitz KK, Gaither CA, et al. Jt Comm J Qual Patient Saf. 2023;49:280-284.

Community pharmacies face unique challenges in ensuring patient safety. This commentary summarizes research on prescribing errors in community pharmacies and how a culture of safety in community pharmacies can drive improvements in prescribing safety.

A decade after Francis: is the NHS safer and more open?

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Martin G, Stanford S, Dixon-Woods M. BMJ. 2023;380:513.

The Francis report served as a call to action for improvement, following its recording of elements contributing to systemic failure within the British National Health Service (NHS). This commentary considers the overarching problems that still exist at the NHS and that listening, learning, and leadership involvement are core elements for driving and realizing lasting change throughout the system.

Comparison of health care worker satisfaction before vs after implementation of a communication and optimal resolution program in acute care hospitals.

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Friedson AI, Humphreys A, LeCraw F, et al. JAMA Netw Open. 2023;6:e232302.

Disclosure of adverse events to patients and families is an important component of safety culture. AHRQ's Communication and Optimal Resolution (CANDOR) program provides tools to guide the disclosure process as well as peer support for healthcare providers (HCP) involved in the adverse event. This study aimed to identify associations with CANDOR implementation and HCP job satisfaction. Results indicate implementation of CANDOR increased some measures of HCP job satisfaction and trust in leadership, a novel finding not previously reported.

AMA Prior Authorization (PA) Physician Survey.

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Chicago, IL: American Medical Association; March 2023.

Insurance policies can have consequences that reduce the safety of medical care. This latest version of the study surveyed 1000 physicians in 2022 to find that prior authorization requirements contributed to patient harm or potentially preventable hospitalization 33 percent of the time.

Crisis in the Lakeshore Hospital ER.

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Derfel A. Montreal Gazette. February 24- March 1, 2023

Emergency room failures are often rooted in system weaknesses. This series examines six patient deaths associated with emergency care that, while concerns were raised by nursing staff, have not been explored to initiate improvements at the facility. Factors contributing to the deaths discussed include nurse shortages, inconsistent oversight, and poor training.

Lessons learned from the RaDonda Vaught ruling.

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Bilski J. Outpatient Surgery. February 2023;16-21

The concept of just culture was challenged in a high-profile medication error resulting in criminal charges for a nurse. This dialogue shares insights on the impact of the case on nurses, their profession, and patient safety.

Measuring Patient Safety

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Perspective on Safety December 14, 2022

This collaborative piece with the Centers for Medicare & Medicaid Services discusses the current state of patient safety measurement, advancements in measuring patient safety, and explores future directions.

In Conversation with Dr. Michelle Schreiber on Measuring Patient Safety

We spoke to Dr. Michelle Schreiber about measuring patient safety, the CMS National Quality Strategy, and the future of measurement. Michelle Schreiber, MD, is the Deputy Director of the Center for Clinical Standards and Quality and the Director of the Quality Measurement and Value-Based Incentives Group at the Centers for Medicare & Medicaid Services.

Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions

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Perspective on Safety November 16, 2022

Human factors engineering or ergonomics (HFE) is a scientific discipline broadly focused on interactions among humans and other elements of a system.

In Conversation with Dr. Michelle Schreiber on Measuring Patient Safety

Missed CANDOR Implementation Opportunities.

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WebM&M Case November 16, 2022

A 58-year-old man underwent a complex surgery to replace his aortic valve. The surgery required prolonged cardiopulmonary bypass time and cross-clamp time and there was a short delay in redosing the cardioplegic solution and the patient developed “stone heart” due to suspected ischemic injury and was unable to come off bypass. The patient was placed on extracorporeal membrane oxygenation (ECMO) and transported to the ICU to allow family members to see the patient before stopping life support.

'Reading the Signals' : Maternity and Neonatal Services in East Kent – the Report of the Independent Investigation.

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Kirkup B. Department of Health and Social Care. London, England: Crown Copyright; 2022. ISBN: 9781528636759.

Maternity care is beset with challenges that reduce safety. This analysis provided insights into improving maternity care in the British National Health Service (NHS) focusing on the need for identification of inadequate performance, enhanced sympathetic care, common purpose in teams, honest response to difficulties and effective outcome measurement.

Medical error and vulnerable communities.

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Jean-Pierre P. Boston U Law Rev. 2022; 102(1):327-392.

Bias and discrimination are receiving overdue attention as primary barriers to patient safety. This article discusses medical error, ineffective response to error, social trust and health care, state apology laws and the role of communication and resolution programs (CRP) to reduce additional harms associated with medical errors, all in the context of marginalized populations.

Failure of crisis leadership in a global pandemic: some reflections on COVID-19 and future recommendations.

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Okoli J, Arroteia NP, Ogunsade AI. Leadersh Health Serv (Bradf Engl). 2023;36:186-199.

At the start of the COVID-19 pandemic, leaders around the world were forced to rapidly made decisions with limited knowledge of the impact those decisions would have on public health. This review of research, policy and the media highlights three cognitive antecedents to crisis leadership failures: 1) ignoring the precautionary principle (e.g., “better safe than sorry”), 2) the illusion of control, and 3) poor uncertainty management tactics. Recommendations for future successful crisis leadership include avoiding optimistic bias, avoiding conflicting information, and frame and communicate risk messages in the right way.

Transparency, public reporting, and a culture of change to quality and safety in cardiac surgery.

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Ibrahim M, Szeto WY, Gutsche J, et al. Ann Thorac Surg. 2022;114:626-635.

Reports of poor care in the media or public reporting systems can serve as an impetus to overhauling hospitals or hospital units. After several unexpected deaths and a drop in several rating systems, this cardiac surgery department launched a comprehensive quality improvement review. This paper describes the major changes made in the department, including role clarity and minimizing variation in 24/7 staffing.

Position Statement on Criminalization of Medical Error and Call for Action to Prevent Patient Harm from Error.

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Cooper J, Thomas BJ, Rebello E, et al for the APSF Criminalization of Error Task Force. APSF Newsletter. October 2022; 37(3):80-81

Criminalizing human error can deter the transparency necessary to learn from incidents and improve health care. This position statement articulates the importance of avoiding the criminal prosecution to mistakes to instead focus on system failures to prevent conditions that permit errors to harm patients.

Veterans Health Administration response to the COVID-19 crisis: surveillance to action.

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Charles MA, Yackel EE, Mills PD, et al. J Patient Saf. 2022;18:686-691.

The first surge of the COVID-19 pandemic forced healthcare organizations to respond to patient safety issues in real-time. The Veterans Health Administration’s National Center for Patient Safety established two working groups to rapidly monitor quality and safety issues and make timely recommendations to staff. The formation, activities, and primary themes of safety issues are described.

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