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 3409 Results

Establishing psychological safety in clinical supervision: multi-professional perspectives.

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Lee EH, Pitts S, Pignataro S, et al. Clin Teach. 2022;19:71-78.

The inherent power imbalance between supervisors and new clinicians may inhibit new clinicians from asking questions or reporting mistakes. This lack of psychological safety can result in patient harm and restrict learning. This article provides strategies for healthcare educators and leaders to model and guide a safer organization. Three phases of the supervisor-learner relationship, along with suggested prompts, are provided.

Presenting complaint: use of language that disempowers patients.

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Cox C, Fritz Z. BMJ. 2022;377:e066720.

As more patients are gaining access to their electronic health records, including clinician notes, the language clinicians use can shape how patients feel about their health and healthcare provider. This commentary describes how some words and phrases routinely used in provider notes, such as “deny” or “non-compliant”, may inadvertently build distrust with the patient. The authors recommend medical students and providers reconsider their language to establish more trusting relationships with their patients.

Communication patterns during routine patient care in a pediatric intensive care unit: the behavioral impact of in situ simulation.

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Ulmer FF, Lutz AM, Müller F, et al. J Patient Saf. 2022;18:e573-e579.

Closed-loop communication is essential to effective teamwork, particularly during complex or high-intensity clinical scenarios. This study found that participation in a one-day simulation team training for pediatric intensive care unit (PICU) nurses led to significant improvements in closed-loop communication in real-life clinical situations.

Patients' experiences and perspectives of patient-reported outcome measures in clinical care: a systematic review and qualitative meta-synthesis.

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Carfora L, Foley CM, Hagi-Diakou P, et al. PLoS ONE. 2022;17:e0267030.

Patients are frequently asked to complete patient-reported outcome measures (PROM), or standardized questionnaires, to assess general quality of life, screen for specific conditions or risk factors, and perspectives on their health. This review identified 14 studies related to patient perspectives regarding PROMs. Three themes emerged: patient preferences regarding PROMs, patient perceived benefits, and barriers to patient engagement with PROMs.

Humanizing harm: using a restorative approach to heal and learn from adverse events.

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Wailling J, Kooijman A, Hughes J, et al. Health Expect. 2022;25:1192-1199.

Harm resulting from patient safety incidents can be compounded if investigating responses ignore the human relationships involved. This article describes how compounded harm arises, and it recommends the use of a restorative practices. A restorative approach focuses on (1) who has been hurt and their needs, and who is responsible for addressing those needs, (2) how harms and relationships can be repaired, and avenues to prevent the incident from reoccurring.

The patient's "story": an examination of patient-reported safety incidents in general practice.

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Madden C, Lydon S, Murphy AW, et al. Fam Pract. 2022;39:1095-1102.

Patient complaints and patient-reported incidents can help identify safety issues. This study compared clinician perceptions and patients’ accounts regarding patient safety incidents and identified a significant difference in perceptions about incident severity. Patients’ accounts of incidents commonly described deficiencies related to communication, staff performance, compassion, and respect.

Identifying patients whose symptoms are underrecognized during treatment with breast radiotherapy.

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Jagsi R, Griffith KA, Vicini F, et al for the Michigan Radiation Oncology Quality Consortium. JAMA Oncol. Epub 2022 Apr 21.

Concordance of patient-reported symptoms and provider-documented symptoms is necessary for appropriate patient care and has clinical implications for research. This study compared patient-reported symptoms (pain, pruritus, edema, and fatigue) following radiotherapy for breast cancer with provider assessments. Underrecognition of at least one symptom occurred in more than 50% of patients. Underrecognition was more common in Black patients and those seen by male physicians. The authors suggest that interventions to improve communication between providers and patients may not only improve outcomes but also reduce racial disparities.

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Díez R, Cadenas R, Susperregui J, et al. Int J Environ Res Public Health. 2022;19:4313.

Older adults living in nursing homes are at increased risk of polypharmacy and its associated adverse outcomes, such as drug-drug interactions. The medication records of 222 older adult residents of one Spanish nursing home were screened for potential drug-drug adverse events. Nearly all included residents were taking at least one potentially inappropriate medication, and drug-drug interactions were common.

Standardized assessment of medication reconciliation in post-acute care.

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Fischer SH, Shih RA, McMullen TL, et al. J Am Geriatr Soc. 2022;70:1047-1056.

Medication reconciliation (MR) occurs during transitions of care and is the process of reviewing a patient’s medication list and comparing it with the regimen being considered for the new setting of care. This study developed and tested standardized assessment data elements (SADE) for reconciliation of high-risk medications in post-acute care settings. The final set included seven elements; results demonstrate feasibility and moderate to strong reliability. The resulting seven data elements may provide the means for post-acute care settings to assess and improve this important quality process.

The effect of a transitional pharmaceutical care program on the occurrence of ADEs after discharge from hospital in patients with polypharmacy.

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Uitvlugt EB, Heer SE, van den Bemt BJF, et al. Res Soc Admin Pharm. 2022;18:2651-2658.

Pharmacists play a critical role in medication safety during transitions of care. This multi-center study found that a transitional pharmacy care program (including teach-back, pharmacy discharge letter, home visit by community pharmacist, and medication reconciliation by both the community and hospital pharmacist) did not decrease the proportion of patients with adverse drug events (ADE) after hospital discharge. The authors discuss several possible explanations as to why the intervention did not impact ADEs and suggest that a process evaluation is needed to explore ways in which a transitional pharmacy care program could reduce ADEs.

Conversations on diagnostic uncertainty and its management among pediatric acute care physicians.

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Patel SJ, Ipsaro A, Brady PW. Hosp Pediatr. 2022;12:317-324.

Diagnostic uncertainty can arise in complex clinical scenarios. This qualitative study explored how physicians in pediatric emergency and inpatient settings mitigate diagnostic uncertainty. Participants discussed common mitigation strategies, such as employing a “diagnostic pause.” The authors also noted outstanding gaps regarding communicating diagnostic uncertainty to families.

Patients should know who's operating, surgeons say.

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Laber-Warren E. MedPage Today. April 5, 2022.

Resident autonomy is an essential component to medical training, but it is not without patient safety risks. This news article highlights situations where resident autonomy should be disclosed to patients (such as instances of overlapping surgeries) and the value of transparency about the role of surgical team members.

We are not there yet: a qualitative system probing study of a hospital rapid response system.

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Olsen SL, Søreide E, Hansen BS. J Patient Saf. 2022;18:717-721.

Rapid response systems (RRS) are widely used to identify signs of rapid deterioration among hospitalized patients. Using in situ simulation, researchers identified obstacles to effective RRS execution, including inconsistent education and documentation, lack of interpersonal trust, and low psychological safety.

Effect of a multispecialty faculty handoff initiative on safety culture and handoff quality.

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Fitzgerald KM, Banerjee TR, Starmer AJ, et al. Pediatr Qual Saf. 2022;7:e539.

I-PASS is a structured handoff tool designed to improve communication between teams at change-of-shift or between care settings. This children’s hospital implemented an I-PASS program to improve communication between attending physicians and safety culture. One year after the program was introduced, all observed handoffs included all five elements of I-PASS and the duration of handoff did not change. Additionally, the “handoff and transition score” on the Agency for Healthcare Quality (AHRQ) Hospital Survey on Patient Safety Culture improved.

Safety of elderly fallers: identifying associated risk factors for 30-day unplanned readmissions using a clinical data warehouse.

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El Abd A, Schwab C, Clementz A, et al. J Patient Saf. 2022;18:230-236.

Older adults are at high risk for 30-day unplanned hospital readmission. This study identified patient-level risk factors among patients 75 years or older who were initially hospitalized for fall-related injuries. Risk factors included being a male, abnormal concentration of C-reactive protein, and anemia. Discharge programs targeting these patients could reduce 30-day unplanned readmissions.

Inviting patients to identify diagnostic concerns through structured evaluation of their online visit notes.

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Giardina TD, Choi DT, Upadhyay DK, et al. J Am Med Inform Assoc. 2022;29:1091-1100.

Most patients can now access their provider visit notes via online portals and many have reported mistakes such as diagnostic errors or missed allergies. This study asked patients who may be “at-risk” for diagnostic error about perceived concerns in their visit notes. Patients were more likely to report having concerns if they did not trust their provider and did not have a good feeling about the visit. Soliciting patient concerns may be one way to improve transparency regarding diagnostic errors and trust in providers.

Family support role in hospital rapid response teams: a scoping review.

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Howlett O, Gleeson R, Jackson L, et al. JBI Evid Synth. 2022;20:2001-2024.

Rapid response teams are designed to provide emergency medical support to deteriorating hospitalized patients. This review examines the role of a family support person (FSP) as part of the rapid response team. The FSP supported the family during the resuscitation in numerous ways, such as explaining jargon and medical procedures and attending to the practical needs of the family.

Psychological intervention to improve communication and patient safety in obstetrics: examination of the health action process approach.

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Derksen C, Kötting L, Keller FM, et al. Front Psychol. 2022;13:771626.

Effective communication and teamwork are fundamental to ensure safe patient care. Building on their earlier systematic review of communication interventions in obstetric care, researchers developed and implemented a training, TeamBaby, to improve communication at two obstetric hospitals. While results did not show a change in communication behavior, perceived patient safety did improve. Additional resources are available in the curated library on maternal safety.

The Cleveland Clinic Pairs Advanced Practice Registered Nurses and Paramedics To Provide Home Visits to Recently Discharged Patients at Highest Risk for Hospital Readmission

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Patient Safety Innovation April 7, 2022

Studies show that home visits to patients recently discharged from the hospital can help prevent unnecessary readmission.¹ Providing continuing care instructions to patients in their homes—where they may be less overwhelmed than in the hospital—may also be a key mechanism for preventing readmission.² Home visit clinicians and technicians can note any health concerns in the home environment and help patients understand their care plan in the context of that environment.²

Implementing a watcher program to improve timeliness of recognition of deterioration in hospitalized children

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Patient Safety Innovation April 7, 2022

A lack of situational awareness can lead to delayed recognition of patient deterioration. This children’s hospital developed and implemented a situational awareness framework designed to decrease emergency transfers to the intensive care unit (ICU).

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