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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 161 - 180 of 16606 Results
Liu LQ, Mehigan S. AORN J. 2021;114:159-170.
Surgical safety checklists (SSC) have been shown to improve outcomes, but effective implementation remains a challenge. This systematic review evaluated the effectiveness of interventions to increase compliance with the World Health Organization’s SSC for adult surgery. Interventions generally fell into one of four categories: modifying the method of SSC delivery, integrating or tailoring the tool for local context, promoting awareness and engagement, and managing organizational policy. Study findings suggest that all approaches resulted in some improvement in compliance.
Kukielka E. Patient Saf. 2021;3:18-27.
Trauma patients, who often suffer multiple, severe injuries and who may arrive to the Emergency Department (ED) unconscious, are vulnerable to adverse events. Using data reported to the Pennsylvania Patient Safety Reporting System (PA-PSRS), researchers in this study evaluated the safety challenges of caring for patients presenting to the ED after a motor vehicle collision. Common challenges included issues with monitoring, treatment, evaluation, and/or documentation, patient falls, medication errors, and problems with transfers.

King AE, Gerolamo AM, Hass RW, et al. J Allied Health. 2021;50(3):175-181.

Teamwork is essential for effective care coordination and patient safety. This study found that this specific educational intervention (TeamSAFE, which consisted of an online learning module and in-person interprofessional teamwork simulations) for medical, nursing, and allied health students improved knowledge of teamwork skills, increased understanding of the roles and responsibilities of different health professions, and the importance of patient safety.  
Hu X, Casey T. J Adv Nurs. 2021;77:3733-3744.
Speaking up about concerns is essential to improving safety, but prior research has found that many healthcare workers do not feel comfortable speaking up. In this study, staff members from a disability healthcare organization in Australia responded to a questionnaire regarding organizational identification and culture of safety. Findings highlight the importance of organizational identification and management commitment to safety and psychological safety in promoting speaking up behaviors.
Gluschkoff K, Kaihlanen A, Palojoki S, et al. Safety Sci. 2021;144:105450.
Organizational culture can influence whether or not clinicians report patient safety incidents. Nurses were surveyed about their experiences with non-reporting of health information technology (HIT)-related safety incidents. Approximately half of respondents indicated that they did not file a report when encountering an HIT-related incident. The authors suggest strengthening organizational culture may increase reporting.
Fernández‐Aguilar C, Martín‐Martín JJ, Minué Lorenzo S, et al. J Eval Clin Pract. 2022;28:135-141.
Heuristics, or the use of mental shortcuts based on experience or trial and error that allow clinicians to quickly assess or diagnose a problem, can sometimes result in misdiagnosis. Three types of heuristics are explored in this study of primary care diagnostic error: representativeness, availability, and overconfidence. While a diagnostic error was identified in nearly 10% of cases, there was no significant correlation between the use of heuristics and diagnostic error.
Burke HB, King HB. BMJ Open. 2021;11:e040779.
This study of US primary care physicians tested their patient safety and quality knowledge. Five topic areas were assessed: 1) patient management, 2) radiation risk, 3) general safety and quality, 4) structure, process, and outcome, and, 5) quality and safety definitions. The average score was 48% correct, indicating additional education in patient safety and quality for practicing primary care physicians is needed.
Bouwman R, Bomhoff M, Robben PB, et al. J Patient Saf. 2021;17:473-482.
When appropriately responded to and addressed, patient complaints may help prevent adverse events. In this study of patient complaints filed with the Dutch Healthcare Inspectorate, researchers investigated how patients expected their complaint would impact healthcare quality, whether patients and regulators had similar expectations, and if expectations are different whether the complaints are clinical or nonclinical in nature. Results show a mismatch between expectations of patients and regulators.
Bosson N, Kaji AH, Gausche-Hill M. Prehosp Emerg Care. 2022;26:492-502.
Pediatric medication administration in prehospital care is challenging due to the need to obtain an accurate weight and calculate dosing. The Los Angeles County emergency medical services implemented a Medical Control Guideline (MCG) to eliminate the need to calculate the dose of a commonly administered medication. Following implementation of the MCG, dosing errors decreased from 18.5% to 14.1% in pediatric prehospital care.
Perspective on Safety October 6, 2021

This piece discusses an expanded view of maternal and infant safety that includes the concept of whole-person care, which addresses the structural and social determinants of maternal health.

This piece discusses an expanded view of maternal and infant safety that includes the concept of whole-person care, which addresses the structural and social determinants of maternal health.

Alison Stuebe photo

Alison Stuebe, MD, MSc, is a professor and Division Director for Maternal-Fetal Medicine in the Department of Obstetrics and Gynecology at the University of North Carolina (UNC) at Chapel Hill and the co-director of the Collaborative for Maternal and Infant Health. Kristin Tully, PhD, is a research assistant professor in the Department of Obstetrics and Gynecology at UNC Chapel Hill and a member of the Collaborative for Maternal and Infant Health. We spoke with them about their work in maternal and infant care and what they are discovering about equitable care and its impact on patient safety.

Ottawa, ON: Canadian Patient Safety Institute; 2008.
This initative defines competency domains for safe health care and outlines educational practices to achieve them. The 2nd edition of the Patient Safety Competencies was released in 2020. 
Atlanta, GA: Centers for Disease Control and Prevention; October 2021.
This annual analysis explores rates of health care-associated infections (HAIs) reported in the United States. Data from 2020 revealed increases in central line–associated bloodstream infections and other infections while a decrease in surgical site infections. The current report also discusses the impact of COVID-19 on reporting and data submission efforts.

Accreditation Council for Graduate Medical Education.

Many graduate medical education programs have instituted patient safety didactics or online courses to meet accreditation standards, but these are likely insufficient in the face of real-world practices commonly witnessed by trainees in clinical settings. Recognizing the importance of this hidden curriculum on shaping trainees' behaviors, the Accreditation Council for Graduate Medical Education (ACGME) created the Clinical Learning Environment Review (CLER) program to evaluate teaching institutions in six focus areas: patient safety, quality improvement, transitions in care, supervision, duty hours, and professionalism. Between June 2017-February 2020, the ACGME visited more than 566 ACGME-accredited institutions as part of this program. According to ACGME leaders, the early findings show an overall lack of trainee engagement in the systems-based practices. Available on the Web site, the latest CLER report describes discoveries from the program and provides a guide for teaching institutions to create clinical environments that support patient safety training and practices.
WebM&M Case September 29, 2021

A 44-year-old man presented to his primary care physician (PCP) with complaints of new onset headache, photophobia, and upper respiratory tract infections. He had a recent history of interferon treatment for Hepatitis C infection and a remote history of cervical spine surgery requiring permanent spinal hardware. On physical examination, his neck was tender, but he had no neurologic abnormalities. He was sent home from the clinic with advice to take over-the-counter analgesics.

WebM&M Case September 29, 2021

This case describes multiple emergency department (ED) encounters and hospitalizations experienced by a middle-aged woman with sickle cell crisis and a past history of multiple, long admissions related to her sickle cell disease. The multiple encounters highlight the challenges of opioid prescribing for patients with chronic, non-cancer pain.

Sood N, Lee RE, To JK, et al. Birth. 2022;49:141-146.
Cesarean delivery can contribute to increased maternal morbidity. This retrospective study found that the introduction of a hospital-wide perioperative bundle significantly reduced surgical site infection rates. The perioperative bundle consisted of five elements (1) an antibiotic protocol, (2) preoperative warming and intraoperative maintenance of normal temperature, (3) standardized surgical preparation for each patient, (4) use of standardized fascial closure trays, and (5) standardized intraoperative application of wound dressing. 
Sauro KM, Machan M, Whalen-Browne L, et al. J Patient Saf. 2021;17:e1285-e1295.
Hospital adverse events are common and can contribute to serious patient harm. This systematic review included 94 studies (representing 590 million admissions from 25 countries) examining trends in hospital adverse events from 1961 to 2014. Findings indicate that hospital adverse events have increased over time and that over half are considered preventable.
Becker C, Zumbrunn S, Beck K, et al. JAMA Netw Open. 2021;4:e2119346.
Discharge from the hospital represents a vulnerable time for patients. This systematic review assessed the impact of discharge communication on hospital readmissions, adherence to treatment regimen, patient satisfaction, mortality, and emergency department visits 30 days after hospital discharge. Findings suggest that improved communication at discharge reduced 30-day hospital readmissions and increased adherence to treatment regimen.
Patient Safety Innovation September 29, 2021

The handshake antimicrobial stewardship program (HS-ASP) was developed and implemented at Children’s Hospital Colorado (CHCO). In 2014, the CHOC HS-ASP team began labeling specific interventions as “Great Catches” which were considered to have altered, or had the potential to alter, the patient’s trajectory of care. CHOC researchers used these "Great Catches" to identify potential diagnostic errors.