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 1930 Results

Clinical progress note: situation awareness for clinical deterioration in hospitalized children.

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Sosa T, Galligan MM, Brady PW. J Hosp Med. 2022;17:199-202.

Situation awareness supports effective teamwork and safe care delivery. This commentary highlights the role of situation awareness in watching the condition of pediatric inpatients to reduce instances of unrecognized clinical deterioration. It features rapid response models enhanced by event review, psychological safety, and patient and family partnering as mechanisms improved through situation awareness.

Lessons Learned about Human Fallibility, System Design, and Justice in the Aftermath of a Fatal Medication Error.

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Institute for Safe Medication Practices and the Just Culture Company. May 6, 2022.

Organizational factors can contribute to the occurrence of patient safety events and how health systems respond to such events. This webinar highlighted lessons learned in the aftermath of a fatal medication error, and strategies to improve patient safety at the organizational level through system design and accountability.

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.

Understanding the link between burnout and sub-optimal care: why should healthcare education be interested in employee silence?

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Montgomery A, Lainidi O. Front Psychiatry. 2022;13:818393.

Difficulty speaking up about patient safety concerns and unprofessional behavior indicates a safety culture deficiency. This article discusses the relationship between silence, burnout, and quality of care, emphasizing how silence evolves during medical education and continues into clinical training, eventually impacting healthcare professional burnout, patient safety and quality of care.

Nebraska Coalition for Patient Safety Annual Report.

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Omaha, NE: Nebraska Coalition for Patient Safety; 2022.

Patient Safety Organizations (PSOs) provide local evidence to inform learning among their members. This annual report describes a state-wide PSO's activities, summarizes breakdowns of data collected between 2008 and 2021, offers insights drawn from an analysis of 1308 incident reports. It also highlights the effects of the COVID pandemic on the program.

The Media’s Role in Patient Safety

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Perspective on Safety April 27, 2022

This piece discusses the role that media plays in affecting patient safety.

In Conversation With... Michael L. Millenson

Michael L. Millenson is the President of Health Quality Advisors LLC, author of the critically acclaimed book Demanding Medical Excellence: Doctors and Accountability in the Information Age, and an adjunct associate professor of medicine at Northwestern University’s Feinberg School of Medicine. He serves on the Board of Directors for Project Patient Care, and earlier in his career he was a healthcare reporter for the Chicago Tribune, where he was nominated three times for a Pulitzer Prize. We spoke with him about how patient safety efforts are shaped by the media and how the role of media has changed since our original discussion on the role of media in patient safety (published in October of 2009 (https://psnet.ahrq.gov/perspective/conversation-charles-ornstein; https://psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safety)).

Toolkit for Preventing CLABSI and CAUTI in ICUs.

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Rockville, MD: Agency for Healthcare Research and Quality; April 2022.

Healthcare-associated infections can result in significant morbidity and mortality. Developed by AHRQ, this customizable, educational toolkit uses the Comprehensive Unit-based Safety Program (CUSP) and other evidence-based practices to provide clinical and cultural guidance to support practice changes to prevent and reduce central line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) rates in intensive care units (ICUs). Sections of the kit include items such an action plan template, implementation playbook, and team interaction aids.

How will state medical boards handle cases involving disclosure and apology for medical errors?

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Wojcieszak D. J Patient Saf Risk Manag. 2022;27:15-20.

Open disclosure and apology for errors is recommended in healthcare. In this study, 38 state medical boards responded to a survey regarding disclosure and apology practices after medical errors. Findings suggest that state medical boards have generally favorable views toward clinicians who disclose errors and apologize, and that these actions would not make the clinician a target for disciplinary action; respondents had less favorable views towards legislative initiatives regarding apologies and disclosure.

Factors associated with workplace violence among healthcare workers in an academic medical center.

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Otachi JK, Robertson H, Okoli CTC. Perspect Psychiatr Care. 2022;58:2383-2393.

Workplace violence in healthcare settings can jeopardize the safety of both patients and healthcare workers. This study found that over half of healthcare workers at one large academic medical center in the United States reported witnessing or experiencing workplace violence. Witnessing or experiencing workplace violence was most common in psychiatric settings and in the emergency department.

Criminalization of human error and a guilty verdict: a travesty of justice that threatens patient safety.

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ISMP Medication Safety Alert! Acute care edition. April 7, 2022; 27(2):1-6.

The Institute for Safe Medication Practices (ISMP) highlights the negative impacts the recent criminal conviction of a nurse could have for patient safety, including fear of reporting errors and clinicians leaving the profession.

Coping and recovery in surgical residents after adverse events: the second victim phenomenon.

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Khansa I, Pearson GD. Plast Reconstr Surg Glob Open. 2022;10:e4203.

Some clinicians experience profound emotional distress following an adverse event, known as the “second victim” phenomenon. This study of surgical residents in the US found that most residents who reported being part of a medical error had subsequent emotional distress, including guilt, anxiety, and insomnia. Importantly, while three quarters of residents reported they did not get emotional support following the event, all those who did get support reported benefiting from it.

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.

Error and cognitive bias in diagnostic radiology.

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Tee QX, Nambiar M, Stuckey S. J Med Imaging Radiat Oncol. 2022;66:202-207.

Diagnostic errors in radiology can result in treatment delays and contribute to patient harm. This article provides an overview of the common cognitive biases encountered in diagnostic radiology that can contribute to diagnostic error, and strategies to avoid these biases, such as the use of a cognitive bias mitigation strategy checklist, peer feedback, promoting a just culture, and technology approaches including artificial intelligence (AI).

Nurses: Guilty verdict for dosing mistake could cost lives.

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Loller T. Associated Press. March 30, 2022.

Reporting medical errors, learning from them, and improving systems is a cornerstone of improving patient safety. A just culture centers on moving from blaming individuals for medical errors towards a systems-based approach to learning what went on, in order to prevent similar errors in the future. The recent conviction of a nurse involved in the death of a patient has raised concerns that clinicians may not disclose medical errors out of fear of criminal prosecution and conviction.

Quality Special Issue.

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J Med Imaging Radiat Oncol. 2022;66(2):165-309.

Improving patient safety related to radiology and radiation oncology is an ongoing priority. This special issue explores themes related to radiology and radiation oncology, including monitoring and improving quality of care, promoting a culture of safety, and measuring, reporting, and learning from errors.

Surveys on Patient Safety Culture (SOPS) Medical Office Survey: 2022 User Database Report.

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Famolaro T, Hare R, Tapia A, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2022. AHRQ Publication No. 22-0017.

The AHRQ Medical Office Survey on Patient Safety Culture is designed to assess safety culture in outpatient clinics. The 2022 comparative data report includes data from 1,100 US medical offices and over 13,000 providers and staff. The highest-scoring composite measures are patient care tracking/follow-up and teamwork. Like the 2020 report, the lowest-scoring measure was work pressure and pace.

Will prosecuting medical errors lead to a culture of silence?

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Fiore K. MedPage Today. March 28, 2022.

Experts are concerned that convictions for medical error have the potential to limit dialogue on the front line about medical mistakes. This article summarizes discussions regarding the verdict to convict a nurse due to a workaround that resulted in a medication error and patient death.

Intrapersonal and institutional influences on overall perception of radiation safety among radiologic technologists.

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Moore QT, Walker DA, Frush DP, et al. Radiol Technol. 2022;93(3):255-267.

Improving patient safety related to radiation delivery is an ongoing priority. This study explores the interpersonal and institutional factors which influence the overall perception of radiation safety culture among U.S. radiologic technologists.

Learning environments, reliability enhancing work practices, employee engagement, and safety climate in VA cardiac catheterization laboratories.

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Gilmartin HM, Hess E, Mueller C, et al. Health Serv Res. 2022;57:385-391.

Ideal clinical learning environments (CLE) support employee engagement, satisfaction, and a culture of safety. The Learning Environment and High Reliability Practices Survey (LEHR) was used to determine the association between ideal CLE and job satisfaction, burnout, intent to leave, and staff turnover. Learning environments with higher average LEHR scores were associated with higher employee engagement, retention, and safety climate scores.

Psychological safety during the test of new work processes in an emergency department.

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Dieckmann P, Tulloch S, Dalgaard AE, et al. BMC Health Serv Res. 2022;22:307.

When staff feel psychologically safe, they are more likely to speak up about safety concerns. This study sought to explore the link between psychological safety and improvement work, and whether an existing model captures all the relevant ‘antecedents’ and ‘consequences’ of psychological safety.

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