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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 1794 Results
Joint Commission.
The Speak Up campaign provides sets of materials to enable patients and families to engage in making their health care experiences as safe as possible. Topics covered include safe surgery, pain management, medication safety, and most recently, how preventive care helps to keep patients healthy and out of the hospital. Each topical package includes infographics, videos, and distribution guidance. Some written materials are available in Spanish.

The Daisy Foundation and Institute for Healthcare Improvement.

Nurses have a fundamental role in safe care delivery by fostering a healthy work environment. This award recognizes nurses that exhibit compassion, patient and family centeredness, and a commitment to workplace safety. The award will be presented at annual IHI Patient Safety Congress. The award nomination process for 2023 closes on December 3.

Armstrong Institute for Patient Safety and Quality, Baltimore, MD. October 3-4, 2023.

Human factors engineering (HFE) is a primary strategy for advancing safety in health care. This virtual workshop will introduce HFE methods and discuss how they can be used to reduce risk through design improvements in a variety of process and interpersonal situations.
Institute for Healthcare Improvement. Boston, MA and online. August 30-October 13, 2023.
Organization executives influence the success of patient safety improvement. This hybrid workshop will highlight how leaders can use assessments, planning, and evidence to improve the safety culture at their organizations.

US Department of Health and Human Services. September 26, 2023. 2:00-3:00 PM (eastern).

Work toward zero harm in health care is gaining national attention in the United States. This webinar aligns with efforts by the National Action Alliance to Advance Patient Safety. The session will explore the successful application of high reliability concepts at the Veterans Health Administration. This is the fifth in a series of offerings from the Alliance supporting its work to improve safety.
California Hospital Patient Safety Organization: Sacramento, CA; 2023.
Patient Safety Organizations (PSOs) capture and analyze local data to inform learning among their 490 members. This report highlights 2022 trends, activities, and outcomes of initiatives at a 21-state PSO. Sections of the report include high-level review of falls and inequities, workplace violence issues, safe table data analysis, and CHPSO's new data platform capabilities.
Joint Commission, National Quality Forum.
The Eisenberg Award honors individuals and organizations who have made key contributions to patient safety and quality improvement. The awards are presented at the National Quality Forum's annual policy conference in Washington, DC. This website provides information on all the recipients and the application process. The 2023 award submission cycle is open through August 21, 2023. 
Patient Safety Innovation July 31, 2023

Concern over patient safety issues associated with inadequate tracking of test results has grown over the last decade, as it can lead to delays in the recognition of abnormal test results and the absence of a tracking system to ensure short-term patient follow-up.1,2 Missed abnormal tests and the lack of necessary clinical follow-up can lead to a late diagnosis.

S Narayan, ed. Manchester, UK: Serious Hazards of Transfusion (SHOT) Steering Group; 2023. ISBN: 9781999596859.
Although errors in the blood transfusion process are rare, they can be harmful. This annual report provides an analysis of transfusion-related errors reported to a national improvement program in the United Kingdom. The 2022 report recommends enhancing focus on underreporting and emergency department report activity as targets for study. Previous reports in the series are available.

Ariadne Labs, Brigham and Women’s Hospital, Harvard TH Chan School of Public Health.

Communication and Resolution Programs (CRP) are a promising strategy for managing the aftermath of medical harm. This 18-month learning collaborative will help participants engage leadership, implement CRP processes, build patient partnerships and establish measurement approaches to gauge the success of CRP efforts. Applications for the 2023-2024 cohort will be accepted until September 1, 2023.

Infect Control Hosp Epidemiol. 2022-2023.

Health care–associated infections (HAIs) affect patients both during and after hospitalization. The use of patient safety methods as well as traditional infection control practices has resulted in significant successes in curbing HAIs such as central-line bloodstream infections. This set of practice guidelines will be developed and disseminated over the course of 2022-2023 to summarize preemptive actions and implementation strategies for prevention of HAIs.
Venesoja A, Tella S, Castrén M, et al. BMJ Open. 2023;13:e067754.
Emergency medical services (EMS) personnel encounter unique safety challenges when delivering patient care. Using focus groups and individual interviews with EMS medical directors and managers in Finland, this qualitative study explored perceptions around patient collaboration to improve safety in EMS. Participants agreed that patient safety is an organizational responsibility and management should provide EMS patients with opportunities to speak up as well as address barriers to voicing concerns.
Short A, McPeake J, Andonovic M, et al. Eur J Hosp Pharm. 2023;30:250-256.
Critical care patients may be vulnerable to medication errors due to the complex nature of the intensive care unit (ICU). This systematic review of 47 studies found that as many as 80% of patients on critical care services experienced medication-related problems after discharge from the hospital. Common problems include inappropriate continuation of newly-prescribed medications as well as discontinuation of chronic disease medications.

ISMP Medication Safety Alert! Acute care edition. June 15, 2023;28(12);1-5.

Pediatric patients are at increased risk of adverse drug events due to weight- and age-based dosing. This article describes additional risk in non-pediatric settings, such as providers’ lack of familiarity with dosing regimens or lack of access to pediatric equipment. Recommendations to reduce risks include appointing pediatric coordinators, designating space for pediatric patients when possible, and collaborating with pediatric institutions to create protocols for care and transfer.
Petrino R, Tuunainen E, Bruzzone G, et al. Eur J Emerg Med. 2023;30:280-286.
The emergency department is a busy and complex environment that can present challenges to patient safety. This survey of emergency medicine professionals from 101 countries identified several patient safety concerns, including workflow and staffing, overcrowding and perceived lack of leadership support. Two PSNet WebM&M commentaries highlight the impact of boarding and overcrowding in the emergency department on patients with a postoperative infection and ruptured abdominal aortic aneurysm.
Saint S, Greene MT, Krein SL, et al. Infect Control Hosp Epidemiol. 2023;Epub Jun 1.
The COVID-19 pandemic challenged infection prevention and control practices. Findings from this survey of infection prevention professionals from acute care hospitals in the United States found that while CLABSI and VAE preventive practices either increased or remained consistent, use of CAUTI preventive practices decreased during the pandemic.
Grailey K, Lound A, Murray E, et al. PLoS One. 2023;18:e0286796.
Effective teamwork is critical in healthcare settings. This qualitative study explored experiences with personality, psychological safety and perceived stressors among emergency and critical care department staff working in the United Kingdom. Findings underscore the ways in which personality traits can influence team performance.
Wolf M, Rolf J, Nelson D, et al. Hosp Pharm. 2023;58:309-314.
Medication administration is a complex process and is a common source of preventable patient harm. This retrospective chart review of 145 surgical patients over a two-month period found that 98.6% of cases involved a potential medication error, most frequently due to potential dose omissions and involving vasopressors, opioids, or neuromuscular blockers.
Patient Safety Innovation May 31, 2023

Seeking a sustainable process to enhance their hospitals’ response to sepsis, a multidisciplinary team at WellSpan Health oversaw the development and implementation of a system that uses customized electronic health record (EHR) alert settings and a team of remote nurses to help frontline staff identify and respond to patients showing signs of sepsis. When the remote nurses, or Central Alerts Team (CAT), receive an alert, they assess the patient’s information and collaborate with the clinical care team to recommend a response.

Patient Safety Innovation May 31, 2023

Patient falls in hospitals are common and debilitating adverse events that persist despite decades of effort to minimize them. Improving communication across the assessing nurse, care team, patient, and patient’s most involved friends and family may strengthen fall prevention efforts. A team at Brigham and Women’s Hospital in Boston, Massachusetts, sought to develop a standardized fall prevention program that centered around improved communication and patient and family engagement.