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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 36 Results
WebM&M Case October 31, 2023

This WebM&M describes two cases illustrating several types of Electronic Health Record (EHR) errors, with a common thread of erroneous use of electronic text-generation functionality, such as copy/paste, copy forward, and automatically pulling information from other electronic sources to populate clinical notes. The commentary discusses other EHR-based documentation tools (such as dot phrases), the influence of new documentation guidelines, and the role of artificial intelligence (AI) tools to capture documentation.

Chicago, IL: American Medical Association; 2023.

The vulnerability of healthcare information technologies and devices to malicious interruptions is increasingly recognized as a patient safety hazard. This eight-episode video series provides an overview for non-technologists on how cyberattacks happen, their potential to degrade care provision, and strategies to keep practices safe.
Monkman H, Kuziemsky C, Homco J, et al. Stud Health Technol Inform. 2023;304:39-43.
Implementation challenges can hinder the safety of telehealth. In this study, medical students used Healthcare Failure Modes and Effect Analysis to identify the causes of failures in telehealth and potential prevention strategies. Four categories of failures were identified: technical issues, patient safety, communication, and social and structural determinants.
Maras SA. Soc Sci Med. 2023;331:116066.
Intimate partner violence (IPV) victims and survivors frequently access healthcare, but don’t always receive trauma-informed care or referrals to IPV resources. This study asked IPV survivors what patient safety meant to them. They described it as care that contained: 1) compassionate and/or trauma-informed care; 2) physically safe spaces; and/or 3) a connection to social resources. Survivors described ways healthcare providers could improve IPV safety.
Denecke K. Stud Health Technol Inform. 2023;302:157-161.
The public is increasingly using conversational assistants like Siri, Alexa, and Google Assistant to find medical advice and self-diagnose. This narrative review summarizes three facets of safety: system (data privacy/security), patient (risks of acting on inaccurate information), and perceived (patient trust in the system). Future research should address all three safety facets, and the results should be transparent to consumers.

Washington DC; Office of Senator Mark Warner: November 25, 2022.

There is lack of consensus concerning the need for increased system and policy attention on cybersecurity challenges as a threat to patient safety. The report suggests modifications within the federal government infrastructure to increase attention to cybersecurity as a safety issue, public/private partnership opportunities, and policy development to reduce the potential for cyberattacks that impact care delivery.
O’Brien N, Shaw A, Flott K, et al. J Glob Health. 2022;12:04018.
Improving patient safety is a global goal. This literature review explored patient safety interventions focused on people living in fragile, conflict-affected, and vulnerable settings. Studies were generally from lower and lower-middle income countries and focused primarily on strengthening infection prevention and control; however, there is a call for more attention on providing patient safety training to healthcare workers, introducing risk management tools, and reducing preventable harm during care delivery.
Schust G, Manning M, Weil A. J Gen Intern Med. 2022;37:2074-2076.
The OpenNotes concept is positioned  to increase patient engagement in their care through error correction and communication enhancement. This commentary highlights concerns associated with privacy involving certain conditions and patient groups that participate in open notes programs. The authors provide recommendations to ensure safety while enabling effective information sharing with all patient populations.
Siewert B, Swedeen S, Brook OR, et al. Radiology. 2022;302:613-619.
Adverse events can contribute to physical, financial, or emotional harm. Based on radiology-related events identified in a hospital incident reporting system, the authors identified the types of incidents contributing to emotional harm in patients – failure to be patient-centered, disrespectful communication, privacy violations, minimization of patient concerns, and loss of property. The authors also proposed several improvement strategies, including communication training and improvement of communication processes, individual feedback, and improvements to existing processes and systems.

Weber L, Jewett C. Kaiser Health News. 2021-2022.

The infectious nature of COVID continues to impact the safety of hospitalized patients. This article series examines factors contributing to hospital-acquired COVID-19 infection that include weaknesses in oversight, patient legal protections, and documentation.
Schneider J, Wirth A. Biomed Instrum Technol. 2021;55:21-28.
Cybersecurity risks in healthcare settings can threaten patient safety. This article outlines the value of a Clinical Director of Cybersecurity, representing a partnership between security-educated clinicians and security professionals. This individual would support development of an effective cybersecurity program through cyber awareness, hygiene (i.e., practices to reduce security risk), management, and cyber-incident response.
Du L, Murdoch B, Chiu C, et al. J Patient Saf. 2021;17:200-206.
Ensuring research participants’ confidentiality is of paramount importance to conducting patient safety research. This article explores how confidentiality is presented in informed consent templates, as compared to current case law in Canada and the United States. Researchers should continue to reassure participants that attempts to force disclosure of confidential research information are rarely successful, and describe the steps taken to protect their confidentiality.
O’Brien N, Ghafur S, Durkin M. J Patient Saf Risk Manag. 2021;26:5-10.
Planned and unplanned electronic heath record (EHR) downtime can have a negative effect on patient safety. This commentary recommends training and education for frontline healthcare workers to help manage cybersecurity attacks in health care. Interventions should be simple and easy to implement and could be based on lessons learned in other areas of patient safety, such as hand hygiene.
Cutler NA, Halcomb E, Sim J, et al. J Clin Nurs. 2021;30:765-772.
Patient safety is an emerging focus within the mental health field. Using qualitative methods, the authors explored environmental influences on patient perceptions of safety in acute mental health settings. Participants highlighted the importance of staff presence, privacy, feeling safe from other patients, and access to meaningful activities (such as meaningful time alone or structured activities).  
Myers LC, Blumenthal K, Phadke NA, et al. Jt Comm J Qual Patient Saf. 2021;47:54-59.
Learning from adverse events is a core component of patient safety improvement. These authors developed guidance for the use of peer review protected information (such as voluntary event reports and root causes analyses) in safety research. The guidance aims to ensure that data are handled safely and appropriately while supporting scientific discovery.  
Vedam S, Stoll K, Taiwo TK, et al. Reprod Health. 2019;16:77.
Ensuring safe, high-quality maternity care is a patient safety priority. This cross-sectional study of 2,138 women in the United States found that one in six women reported experiencing mistreatment during maternity care. Researchers found that women of color and women giving birth in hospitals (versus at home) were more likely to experience mistreatment. The most common forms of mistreatment were being yelled at or scolded by a health care provider, being ignored, violations of physical privacy, and threats to withhold treatment or being forced to accept treatment they did not want.
Ramjist JK, Coburn N, Urbach DR, et al. JAMA. 2018;319:1162-1163.
A privacy breach is a type of patient harm. Investigators collected a large volume of recycled paper waste from multiple hospitals and found protected health information that should have been disposed of in a more secure fashion. The authors suggest systems approaches to avoid privacy breaches related to paper medical records.

ISMP Medication Safety Alert! Acute Care Edition. June 29, 2017;16:1-5.

Adopting new technologies in health care can have unintended consequences that diminish patient safety. This newsletter article explores the impact of texting in health care, reviews both improvements and problems associated with the practice, and notes limited understanding regarding their occurrence. A past WebM&M commentary discussed problems stemming from an interruption caused by texting.