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 12120 Results

Ten years later, alarm fatigue is still a safety concern.

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Albanowski K, Burdick KJ, Bonafide CP, et al. AACN Adv Crit Care. 2023;34:189-197.

Alarm (or alert) fatigue occurs when clinicians ignore alarms, usually due to the majority being invalid or nonactionable, and thus fail to respond or respond more slowly to actionable alerts. The article describes the progress made in reducing nonactionable alarms and making actionable alarms more useful to responding clinicians. Clinical approaches include customization of alert parameters to reduce nonactionable alarms, while engineering solutions include reducing the volume or adjusting the tone of auditory alerts.

Preventing potential patient harm through clinical content interventions during oncology clinical trial implementation.

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Loo VC, Kim S, Johnson LM, et al. J Patient Saf. 2023;19:460-464.

Ensuring the safety of clinical trial participants is paramount to successful, meaningful clinical research. In this study, researchers examined 585 clinical trial documents and found that 17% included potential patient safety interventions (e.g., resolving medication dosing discrepancies). The authors suggest that clinical specialists’ review of study protocol documents could enhance patient safety during clinical trial conduct.

Factors associated with neuroradiologic diagnostic errors at a large tertiary-care academic medical center: a case-control study.

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Ivanovic V, Broadhead K, Beck R, et al. AJR Am J Roentgenol. 2023;221:355-362.

Like many clinical areas, a variety of system factors can influence diagnostic error rates in neuroradiology. This study included 564 neuroradiologic examinations with diagnostic error and 1,019 without error. Diagnostic errors were associated with longer interpretation times, higher shift volume, and weekend interpretation.

‘Dr. Google’ meets its match: Dr. ChatGPT.

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Leonard A. KFF Health News. September 12, 2023.

The use of artificial intelligence (AI) holds potential for health care improvement that is beginning to be documented. This article discusses ChatGPT in the context of wide availability of internet search tools as a mechanism for patients to find answers to clinical questions. It summarizes clinicians’ concerns about the tools and strategies to being used to ensure the accuracy and safety of these searches.

Impact of pharmacist-led admission medication reconciliation on patient outcomes in a large health system.

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Kramer JS, Hayley Burgess L, Warren C, et al. J Patient Saf Risk Manag. 2023;Epub Aug 27.

Obtaining a best possible medication history (BPM) is an important component of successful medication reconciliation programs. This study compared the impact of a pharmacy-led medication reconciliation program including BPMH on adverse drug events (ADEs) and complications among high-risk, complex patients across 16 hospitals. In the six months following implementation, 80,000 reconciliations were completed and nearly 40% required additional medication follow-up and/or clarification. Researchers identified a statistically significant decrease in both ADEs and complications after implementation.

Uncovering the shocking dangers of misdiagnosis.

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Graedon T. People’s Pharmacy. Show 1355. September 8, 2023.

Misdiagnosis continues to impact the safety of health care. This podcast with David Newman-Toker discusses foundational issues that detract from diagnostic safety and examines how teamwork, training, technology, tuning can make the process more reliable. Strategies for patients to play a role in their diagnostic process are also discussed.

From battles to burnout: investigating the role of interphysician conflict in physician burnout.

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Amick AE, Schrepel C, Bann M, et al. Acad Med. 2023;98:1076-1082.

Disruptive behaviors, including experiencing or witnessing coworker conflict, can lead to staff burnout and adverse events. In this study, emergency medicine and internal medicine physicians reported on conflicts with other physicians they'd experienced in the workplace. Participants reported feeling demoralized and burnt out after a conflict and brought those feelings to future interactions, priming the situation for additional conflict.

Global Knowledge Sharing Platform for Patient Safety.

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World Health Organization.

The sharing of best practices is a key component of enabling successful strategy implementation in support of patient safety plans and goals. This website will capture, organize, and share experiences worldwide to support knowledge sharing and community building to reduce World Patient Safety Day targeted challenges.

Wake-up call: night shifts adversely affect nurse health and retention, patient and public safety, and costs.

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Imes CC, Tucker SJ, Trinkoff AM, et al. Nurs Adm Q. 2023;47:E38-E53.

Extended and overnight shifts are associated with higher adverse event rates and burnout. This mini review summarizes the impact of overnight shifts on nurses' health, patient and public safety, and organizational costs (e.g., those related to nurse turnover). Organizational strategies to promote nurses' health and reduce errors are also summarized, ranging from low-cost measures such as breaks for physical activity during the shift to high-cost measures such as referral to sleep specialists or paid transportation home.

Defining speaking up in the healthcare system: a systematic review.

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Kane J, Munn L, Kane SF, et al. J Gen Intern Med. 2023;Epub Sept 5.

Clinicians and staff are encouraged to speak up about safety concerns as a part of patient safety culture. This review had two aims: to review the literature on speaking up for patient safety, and to develop a single definition of "speaking up" in healthcare. 294 articles were identified with 51 directly focused on speaking up and the remaining on other aspects such as communication. 11 distinct definitions were identified from which the authors developed a single definition: a healthcare professional identifying a concern that might impact patient safety and using his or her voice to raise the concern to someone with the power to address it.

Towards diagnostic excellence on academic ward teams: building a conceptual model of team dynamics in the diagnostic process.

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Choi JJ, Rosen MA, Shapiro MF, et al. Diagnosis (Berl). 2023;Epub Aug 11.

Teamwork is increasingly seen as an important component of diagnostic excellence. Through a systematic review and observations of team dynamics in a hospital medical ward, researchers identified three areas requiring additional research- (1) team structure, (2) contextual factors, and (3) emergent states (e.g., shared mental models).

Enhancing patient safety: a national standard for cyber resiliency in healthcare.

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Samuelson-Kiraly C, Mitchell JI, Kingston D, et al. Healthc Manage Forum. 2023;Epub Aug 30.

The threat of cybersecurity risks to patient safety is receiving increasing attention. This article describes the development of a new standard to support cyber resiliency in Canada’s healthcare system. The guidance addresses key areas of concern (e.g., organizational risk management, technology considerations, contingency planning), provides suggested roles and responsibilities for an organizational cybersecurity team, and emphasizes the importance of cyber incident response planning.

Improving patients' intensive care admission through multidisciplinary simulation-based crisis resource management: a qualitative study.

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Jensen JF, Ramos J, Ørom M‐L, et al. J Clin Nurs. 2023;32:7530-7542.

Crisis (or crew) resource management (CRM) training focuses on improvement of non-technical skills such as communication, teamwork, and situational awareness. This quality improvement project consisted of simulation-based CRM training in the context of intensive care unit admission. Interviews with participants, conducted three months after the simulation, revealed several themes including reflections on patient safety. Participants described positive changes in workflow, professional standards, and smoother and controlled processes.

Making Healthcare Safer IV: A Continuous Updating of Patient Safety Harms and Practices.

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Rockville, MD: Agency for Healthcare Research and Quality: September 2023.

Patient safety progress is dynamic, consistently producing evidence for application to generate improvements. This report is the fourth in a series funded by the Agency for Healthcare Research and Quality to track a prioritized set of emerging and existing safety approaches to confirm their value and effectiveness. This report will be compiled as new conclusions are formulated. Each review will be posted to the collection as they are completed. The first three Making Healthcare Safer reports, published in 2001, 2013, and 2020, have each served as a consolidated evidence source for clinicians, health system leadership, researchers, and government agencies. Chapter protocols and the results of an examination of harms associated with video-based telehealth are now available.

Intensive care unit critical incident analysis as an objective tool to select content for a simulation curriculum.

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Yartsev A, Yang F. Simul Healthc. 2023;18:279-282.

Intensive care units (ICUs) are complex care environments at high risk for medical errors. In this retrospective study, researchers identified the occurrence of common ICU scenarios and skills during code blue events and measured trainees’ self-reported confidence in these skills. The analysis found that more than 25% of trainees reported low levels of confidence in three scenarios – familiarity with the advanced life support trolley, electrocardiogram strip interpretation, and operation of an external defibrillator. This process of integrating critical incident data with trainee self-assessment can be generalized to other clinical scenarios to create targeted education and simulation curriculum.

Physician perspectives on responding to clinician-perpetuated interpersonal racism against Black patients with serious illness.

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Brown CE, Snyder CR, Marshall AR, et al. J Gen Intern Med. 2023;Epub Aug 24.

Structural racism continues to perpetuate health disparities. As part of their study on how black patients with serious illness experience racism from providers, researchers conducted interviews with 21 providers to understand ways they address anti-Black racism in their practice. Providers felt unprepared to address racism with their patients, wanted to provide tools for patients to bring up their experiences while also acknowledging the additional burden this would place on Black patients, and thought patient- and provider-facing programs could facilitate discussions. Additionally, despite extensive research on the negative impacts of structural racism on health, participants cited the need for more data.

Radiographers' experience of preventing patient safety incidents in the context of radiological examinations.

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Wallin A, Ringdal M, Ahlberg K, et al. Scand J Caring Sci. 2023;37:414-423.

Numerous factors can hinder safe radiology practices, such as communication failures and image interpretation errors. Based on semi-structured interviews with 17 radiologists in Sweden, this study identified 20 themes at the individual-, organization-, technology-, task-and environment-levels describing factors supporting patient safety in radiology. Factors described by participants included the use of standardized tools and work routines (e.g., checklists), handoffs, and incident reporting systems.

Assessing the utility of ChatGPT throughout the entire clinical workflow: development and usability study.

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Rao A, Pang M, Kim J, et al. J Med Internet Res. 2023;25:e48659.

Interest in testing ChatGPT as a clinical tool is increasing. This study asked ChatGPT to provide a differential diagnosis, diagnostic testing, final diagnosis, and care management for 36 previously published clinical vignettes. ChatGPT had an overall accuracy of 72%, with the highest level of accuracy at the final diagnosis stage (77%).

Work system barriers and facilitators of a team health information technology.

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Hose B-Z, Carayon P, Hoonakker PLT, et al. Appl Ergon. 2023;113:104105.

Health information technology (IT) usability continues to be a source of patient harm. This study describes the perspectives of a variety of pediatric trauma team members (e.g., pediatric emergency medicine attending, surgical technician, pediatric intensive care unit attending) on the usability of a potential team health IT care transition tool. Numerous barriers and facilitators were identified and varied across department and role.

In search of an international multidimensional action plan for second victim support: a narrative review.

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Seys D, Panella M, Russotto S, et al. BMC Health Serv Res. 2023;23:816.

Clinicians who are involved in a patient safety incident can experience psychological harm. This literature review of 104 studies identified five levels of support that can be provided to healthcare workers after a patient safety incident – (1) prevention, (2) self-care of individuals and/or teams, (3) support by peers and triage, (4) structured professional support, and (5) structured clinical support.

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