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.
Drey N, Gould D, Purssell E, et al. BMJ Qual Saf. 2020;29:756-763.
This thematic analysis explored variations in the impact of hand hygiene interventions to prevent healthcare-associated infections. The analysis identified several directions for future research, including exploring ways to avoid the Hawthorne effect, embed the interventions into wider patient safety initiatives, and develop systematic approaches to implementation.
Wood LJ, Wiegmann DA. Int J Qual Health Care. 2020;32:438-444.
This article discusses the action hierarchy, which is a tool for generating corrective actions to improve safety and focuses on those recommendations relying less on human factors and more on systems change. The authors propose a multifaceted definition of ‘systems change’ and a rubric for determining the extent to which a corrective action addresses ‘systems change’ (‘systems change hierarchy’).
Arnetz JE, Neufcourt L, Sudan S, et al. J Nurs Care Qual. 2020;35:206-212.
Based on survey responses from nurses at one large US hospital, this study examined the association between nurse-reported bullying and nurse-sensitive patient outcomes (patient falls, central-line-associated blood stream infections, catheter-associated urinary tract infections, hospital-acquired pressure ulcers, and ventilator-associated events). The researchers found that nurse-reported bullying was significantly associated with the incidence of central-line-associated blood stream infections. Addressing nurse bullying at work may reduce certain adverse events.
Giardina TD, Royse KE, Khanna A, et al. Jt Comm J Qual Patient Saf. 2020;46:282-290.
This study analyzed self-reported adverse events captured on a national online questionnaire to determine the association between patient-reported contributory factors and patient-reported physical, emotional or financial harm. Contributory factors identified in the analysis focused on issues with health care personnel communication, fatigue, or response (e.g., doctor was slow to arrive, nurse was slow to respond to call button). These patient-reported contributory factors increased the likelihood of reporting any type of harm.