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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 108 Results
Curated Libraries
September 13, 2021
Ensuring maternal safety is a patient safety priority. This library reflects a curated selection of PSNet content focused on improving maternal safety. Included resources explore strategies with the potential to improve maternal care delivery and outcomes, such as high reliability, care standardization,teamwork, unit-based safety initiatives, and...
Biquet J-M, Schopper D, Sprumont D, et al. J Patient Saf. 2021;17:e1738-e1743.
Few medical humanitarian organizations have patient safety reporting and analysis systems. Interviews with medical and paramedical staff working in international humanitarian organizations expressed high expectations for organizational leadership to establish clear patient safety and medical error management policies.  
LeCraw FR, Stearns SC, McCoy MJ. J Patient Saf Risk Manag. 2021;26:34-40.
Healthcare systems have implemented communication-and-resolution programs (CRPs) to respond and disclose serious errors and adverse events. This article describes methods used by nine teams of CRP advocates to encourage adoption and endorsement by hospitals and national medical societies at the national, state, and local levels.  
Rogith D, Satterly T, Singh H, et al. Appl Clin Inform. 2020;11:692-698.
Lack of timely follow-up of test results is a recognized patient safety problem in primary care and can lead to missed or delayed diagnoses. This study used human factors methods to understand lack of timely follow-up of abnormal test results in outpatient settings. Through interviews with the ordering physicians, the researchers identified several contributing factors, such as provider-patient communication channel mismatch and diffusion of responsibility.
Denning M, Goh ET, Scott A, et al. Int J Environ Res Public Health. 2020;17:7034.
This study used the Safety Attitudes Questionnaire to evaluate the impact of COVID-19 on safety culture at a large UK teaching hospital compared to baseline scores collected in 2017. Overall, respondents reported more positive perceptions of safety; training and support for redeployment were associated with higher perceptions of safety. However, the analysis identified a significant decrease in error reporting after the onset of the COVID-19 pandemic.
Kalánková D, Kirwan M, Bartoníčková D, et al. J Nurs Manag. 2020;28:1783-1797.
This scoping review assessed 44 studies to describe the scope of the evidence of the impact of missed, rationed and unfinished nursing care on patient-related outcomes; 9 of these studies focused on the impact on patient safety outcomes. The review concludes that medication errors as the biggest threat to patient safety resulting from missed, rationed or unfinished care, and that falls (with or without injury) and hospital-acquired infections are the most common resulting adverse events. These adverse events are attributed to the omission of preventive nursing care activities, such as handwashing, patient education and maintaining a safe environment.
Nakhleh RE, Volmar KE, eds. Cham, Switzerland: Springer Nature; 2019. ISBN: 9783030184636.
Surgical specimen and laboratory process problems can affect diagnosis. This publication examines factors that contribute to errors across the surgical pathology process and reviews strategies to reduce their impact on care. Chapters discuss areas of focus to encourage process improvement and error response, such as information technology, specimen tracking, root cause analysis, and disclosure.
Desai S, Fiumara K, Kachalia A. J Patient Saf. 2021;17:e84-e90.
Outpatient safety is gaining recognition as a focus of research and improvement efforts. This project report describes an ambulatory safety program at an academic health system that targeted reporting, safety culture measurement, medication safety, and test result management. Repeated tracking over a 5-year period revealed that failure to request feedback played a role in the modest incident and concern reporting captured by the program. Decentralizing reporting response responsibilities throughout the system significantly increased feedback activity.
Cullen A. Uitgeverij van Brug: The Hague, The Netherlands; 2019. ISBN: 9789065232236.
Patient stories offer important insights regarding the impact medical errors have on patients and their families. This book shares the author's experience with medical error and spotlights how lack of transparency in European health care can contribute to avoidable process failures that result in patient harm.
Gupta A, Jain S, Croft C. JAMA. 2019;321:504-505.
The authors present a case in which an unnecessary procedure was incorrectly performed on a patient who had opted to pursue hospice care. They highlight factors contributing to the error including those related to use of the electronic health record.
Dy CJ, Osei DA, Maak TG, et al. J Bone Joint Surg Am. 2018;100:1902-1911.
Overlapping surgery is a controversial practice in which an attending surgeon performs more than one procedure concurrently. This retrospective cohort of overlapping orthopedic surgeries across five academic institutions found no differences between complication rates for overlapping versus nonoverlapping procedures. The authors recommend individualizing decisions regarding overlapping surgeries.
Aiken LH, Sloane DM, Barnes H, et al. Health Aff (Millwood). 2018;37:1744-1751.
Factors in the hospital work environment can affect nurses' ability to provide safe care. In this survey study, investigators examined trends in nurse ratings of their work environment and patient ratings of care quality at 535 hospitals between 2005 and 2016. Over this time frame, about 20% of hospitals showed significant improvements in work environment scores, while 7% of hospitals demonstrated declining scores. There was an association between an improving work environment and better patient satisfaction. The authors conclude that lack of improvement in work environments may worsen safety culture and impede efforts to enhance patient safety. A PSNet interview with Linda Aiken discussed how nurse staffing and the work environment can affect patient safety and outcomes.
Ai A, Desai S, Shellman A, et al. Jt Comm J Qual Patient Saf. 2018;44:674-682.
This study examined ambulatory follow-up of test results by aggregating multiple types of data—national surveys on safety culture and patient satisfaction; patient complaints; safety reports; and electronic health record audits of provider response times. Researchers found an association between quicker response time for test results and higher patient satisfaction. They conclude that merging these disparate data sources can uncover new levers to improve patient safety.
Cardiello R, Johnston S, Kiely S. J Healthc Risk Manag. 2019;38:24-31.
Patient safety hotlines are an established method for clinicians and patients to report safety concerns. This commentary describes how one organization implemented a hotline for patients to report concerns. The authors discuss their experiences in working with vendors and analysis of the program results to inform future work.
Persico N, Maltese F, Ferrigno C, et al. Ann Emerg Med. 2018;72:171-180.
This study team performed cognitive testing on emergency medicine physicians following nights spent at home versus after 14-hour and 24-hour shifts. They did not find any decrement in performance after a 14-hour shift compared to a night of rest. However, physicians' processing speed, working memory, and perceptual reasoning were worse after a 24-hour shift, suggesting that 24-hour shifts for emergency medicine physicians should be limited.
Snowden JM, Kozhimannil KB, Muoto I, et al. BMJ Qual Saf. 2017;26:e1.
This study found that perinatal complications of childbirth, including low Apgar scores, neonatal seizures, and postpartum hemorrhage, were more prevalent during the weekend, echoing the weekend effect in other health settings. Higher patient volume was also associated with worse outcomes, consistent with prior studies of nurse staffing ratios. These results argue for staffing changes to ensure safety at busy times and outside usual business hours.
Robinson EJ, Smith GB, Power GS, et al. BMJ Qual Saf. 2016;25:832-841.
Patients admitted on the weekend may be at increased risk for complications and mortality. This analysis of a large national database examined variations in outcomes following in-hospital cardiac arrest by day versus night and weekday versus weekend. The investigators found that return of spontaneous circulation for 20 minutes or longer, a positive outcome, was more likely during weekday business hours compared with nights or weekends. Similarly, survival to hospital discharge was worse on nights and weekends. These results are consistent with prior studies that demonstrated worse outcomes for patients admitted to hospitals during nights or weekends. Raising concerns that patients who had in-hospital cardiac arrest on nights or weekends might have been more ill at baseline, a related editorial encourages rigorous evaluation of any staffing changes meant to address the weekend effect.
Faisy C, Davagnar C, Ladiray D, et al. Int J Nurs Stud. 2016;62:60-70.
Higher patient-to-nurse staffing ratios have been linked to worse patient outcomes. In this 8-year observational cohort study in a single intensive care unit, increased patient-to-nurse staffing ratios and arrival of inexperienced resident physicians were associated with higher rates of adverse events including unexpected cardiac arrest, unanticipated extubation, and readmission.
Lin H, Lin E, Auditore S, et al. Acad Med. 2016;91:140-50.
Seminal studies and widely publicized cases linking fatigue among trainee physicians with medical errors led to rules that limited duty hours for residents, but the evidence has been mixed regarding whether reduced work hours have enhanced safety. This narrative review found that resident well-being improved following duty hour reforms. Patient safety may have improved, but, if so, the effects were small. More research is needed to determine the effect of duty hours changes on resident education and hospital costs.
Govindarajan A, Urbach DR, Kumar M, et al. N Engl J Med. 2015;373:845-53.
The link between lack of sleep and subsequent medical errors served as an impetus for physician duty-hours reform. In trainee physicians, sleep loss is associated with attentional failures, but little is known about the relationship between attending physician performance and sleep loss. This retrospective cohort study examined outcomes of elective surgical procedures among attending surgeons who had worked after midnight on the previous night versus those who had not. The investigators found no differences in mortality, complications, or readmissions between procedures performed by surgeons with sleep loss compared to those without sleep loss, mirroring results of an earlier simulation study. This may be due to greater technical skill among attending surgeons, or the ability to cancel or postpone elective procedures as needed at times of fatigue. This study included many institutions, physicians, and procedure types, suggesting that short-term sleep deprivation might not be a high-yield safety target for attending surgeons.