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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 - 13 of 13 Results
Klatt TE, Sachs JF, Huang C-C, et al. Jt Comm J Qual Patient Saf. 2021;47:759-767.
This article describes the implementation of a peer support program for “second victims” in a US healthcare system. Following training, peer supporters assisted at-risk colleagues, raised awareness of second victim syndrome, and recruited others for training. The effectiveness of the training was assessed using the Second Victim Experience Support Tool. The most common event supported was inability to stop the progress of a medical condition, including COVID-19.
Preston-Suni K, Celedon MA, Cordasco KM. Jt Comm J Qual Patient Saf. 2021;47:673-676.
Presenteeism among healthcare workers – continuing to work while sick – has been attributed to various cultural and system factors, such as fear of failing colleagues or patients. This commentary discusses the patient safety and ethical considerations of presenteeism during the COVID-19 pandemic
Dhahri AA, Refson J. BMJ Leader. 2021;5:203-205.
Hierarchy and professional silos can disrupt collaboration. This commentary describes one hospital’s approach to shifting the surgical leadership role to facilitate communication and cross-organizational influence to affect quality and safety performance.
Andel SA, Tedone AM, Shen W, et al. J Adv Nurs. 2021;78:121-130.
During the first weeks of the COVID-19 pandemic, 120 nurses were surveyed about nurse-to-patient staffing ratios, skill mix, and near misses in their hospitals. Personnel understaffing led to increased use of workarounds, and expertise understaffing led to increased cognitive failures, both of which shaped near misses. Hospital leaders should recognize both forms of understaffing when making staffing decisions, particularly during times of crisis.
Adelman JS, Gandhi TK. J Patient Saf. 2021;17:331-333.
The full impact of the COVID-19 pandemic on patient safety in the healthcare system is still unknown. New patient safety concerns have been introduced, and existing concerns have been exacerbated. The authors suggest several high reliability strategies to prevent and learn from patient safety hazards, including transparency, a culture of safety, and continuous analysis of errors.
Denning M, Goh ET, Tan B, et al. PLoS One. 2021;16:e0238666.
This cross-sectional study conducted from March to June 2020 measured anxiety, depression, and burnout in clinicians working in the United Kingdom, Poland, and Singapore. Approximately 70% of respondents reported feeling anxious, depressed and/or burnt out. Burnout was significantly inversely correlated with being tested for COVID-19 and perceiving high levels of safety. These findings highlight the importance of supporting staff well-being and proactive COVID-19 testing.
Haidari E, Main EK, Cui X, et al. J Perinatol. 2021;41:961-969.
High levels of healthcare worker (HCW) burnout may be associated with lower levels of patient safety and quality. In June 2020, three months into the COVID-19 pandemic, 288 maternity and neonatal HCWs were asked about their perspectives on well-being and patient safety. Two-thirds of respondents reported symptoms of burnout and only one-third reported adequate organizational support to meet these challenges. Organizations are encouraged to implement programs to reduce burnout and support HCW well-being.
Kozasa EH, Lacerda SS, Polissici MA, et al. Front Psych. 2020;11:570786.
Situational awareness during critical incidents is a key component of teamwork. This study found that a mutual care training can increase situational awareness for healthcare workers and consequently improve mental health and well-being before and during the COVID-19 pandemic.

McGaffigan P, Gerwig K, Kingston MB. Healthcare Executive. 2020 Nov;35(6):48-50.

Health care workforce satisfaction is the responsibility of leadership and it is reliant on the organizational safety culture. This article highlights the importance of worker conditions as a component of safety and summarizes recommendations for keeping workers safe and thriving.

ISMP Medication Safety Alert! Acute care edition. August 27, 2020;25(17).

The culture of blame is exacerbated by stress, production pressure, and a negative work environment. This article discusses how medication errors that take place during the care of patients with COVID-19 are not being reported by nurses due to lack of time and psychological safety. Recommendations to avoid this situation include heightening prevention efforts by employing tactics such as deployment of huddles and use of pre-mixed medication solutions.  

Yong E. The Atlantic. September 2020

This article takes a holistic view of the multiple preventable failures of the U.S. in managing the COVID-19 pandemic, raising several patient safety issues from the metasystems perspective. The piece highlights systemic problems such as lack of transparency, investment in public health and learning from experience.
Rangachari P, L. Woods J. Int J Environ Res Public Health. 2020;17:4267.
This article discusses the impact of the lack of healthcare worker support on resilience, patient safety, and staff retention during the COVID-19 pandemic and provides recommendations for better supporting psychological safety among healthcare workers.