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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 - 19 of 19 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.

Ellis NT, Broaddus A. CNN. August 25, 2021. 

Maternal safety is an ongoing challenge worldwide. This news feature examines how the COVID pandemic has revealed disparities and implicit biases that impact the maternal care of black women. The stories shared highlight experiences of mothers with preventable pregnancy-related complications.
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.
Melnyk BM, Tan A, Hsieh AP, et al. Am J Crit Care. 2021;30:176-184.
This survey of 771 critical care nurses found that 40% had at least one symptom of depression and nearly half experienced some degree of anxiety. Nurses with poor physical or mental health reported making more medical errors than their healthier counterparts and nurses in supportive workplaces were more likely to have better physical and mental health. The authors suggest that improvements in an organization’s health and wellness support programs could result in fewer reported medical errors. Notably, this study was completed prior to the COVID-19 pandemic which has led to an even further decline in nurse wellness. 

Washington, DC: Department of Veterans Affairs, Office of Inspector General. June 24, 2021. Report No. 19-09808-171.

This report examined veterans' health clinic use of telemental health to identify safety challenges inherent in this approach before the expansion of telemedine during the COVID-19 crisis. The authors note the complexities in managing emergent mental health situations in virtual consultations. Recommendations for improvement included emergency preparedness planning, specific reporting of telemental health incidents and organized access to experts.
Kakemam E, Chegini Z, Rouhi A, et al. J Nurs Manag. 2021;29:1974-1982.
Clinician burnout, characterized by emotional exhaustion, depersonalization, and decreased sense of accomplishment, can result in worse patient safety outcomes. This study explores the association of nurse burnout and self-reported occurrence of adverse events during COVID-19. Results indicate higher levels of nurse burnout were correlated with increased perception of adverse events, such as patient and family verbal abuse, medication errors, and patient and family complaints. Recommendations for decreasing burnout include access to psychosocial support and human factors approaches.
Thompson R, Kusy M. Nurs Adm Q. 2021;45:135-141.
Effective leadership is essential to team performance and organizational safety. This article discusses the role of team leaders on team performance during the COVID-19 pandemic. The authors review common mistakes made during the pandemic (such as broken trust or ignoring disruptive behaviors) and lessons learned to help build strong, cohesive teams.
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.
González-Gil MT, González-Blázquez C, Parro-Moreno AI, et al. Intensive Crit Care Nurs. 2021;62:102966.
The COVID-19 pandemic has resulted in concerns about psychological and emotional well-being of health care professionals. In this cross-sectional study, critical care and emergency nurses in Spain report fears of COVID-19 infection, elevated workloads, higher nurse-to-patient ratios, communication struggles with management, and socio-emotional challenges in caring for their patients and themselves during the pandemic.
Stark N, Kerrissey M, Grade M, et al. West J Emerg Med. 2020;21:1095-1101.
This article describes the development and implementation of a digital tool to centralize and standardize COVID-19-related resources for use in the emergency department (ED). Clinician feedback suggests confirms that the tool has affected their management of COVID-19 patients. The tool was found to be easily adaptable to accommodate rapidly evolving guidance and enable organizational capacity for improvisation and resiliency.  
Waldman A, Kaplan J. ProPublica. 2020.
Hospitals have been deeply challenged to provide effective care during the COVID crisis. This article discusses how rationing and ineffective protection for families and patients may have contributed to preventable death and the spread of the virus in families due to unnecessary referrals of patients to home care and hospice.

O'Donnell J. USA Today. September 8, 2020

Management and clinical functions to ensure patient safety have been disrupted during the COVID-19 pandemic. This article discusses how tracking and submitting of reports of questionable medical care have been reduced due to redirection of efforts of all to managing pandemic related activities.   
Lasater KB, Aiken LH, Sloane DM, et al. BMJ Qual Saf. 2021;8:639-647.
This study used survey data from nurses and patients in 254 hospitals in New York and Illinois between December 2019 and February 2020 to determine the association between nurse staffing and outcomes, patient experience, and nurse burnout. A significant number of nurses who experienced burnout viewed their hospitals’ safety unfavorably and would not recommend their hospital. Analyses indicated that each additional patient per nurse increased the odds of unfavorable reports from nurses and patients and demonstrates the implications of understaffing, even before COVID-19.    
Bender WR, Srinivas S, Coutifaris P, et al. Am J Perinatol. 2020;37:1271-1279.
This cohort explored the mental health impacts of a universal COVID-19 testing program on asymptomatic pregnant women and labor and delivery health care workers. Among multiparous women who tested negative, nearly 35% reported that COVID-19 led to additional fear or anxiety postpartum compared with previous deliveries. Labor and delivery health care workers reported that COVID-19 decreased job satisfaction and increased job-related anxiety.

Rockville, MD; Agency for Healthcare Research and Quality: 2020.

The COVID-19 pandemic is placing surge demand and strain on health organizational, department, and unit-level capacity and personnel. This announcement features a prototype tool as a model for health systems to evaluate hospital-specific demand for medical and intensive care unit beds and the needed equipment to equip staff to keep patients safe during shifting conditions associated with providing care during an emerging crisis.
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. 
Cai H, Tu B, Ma J, et al. Med Sci Monit. 2020;26:e924171.
Production pressure – the pressure to continue to work at maximum capacity – presents risks to patient safety. This study reported on a survey of 534 healthcare providers and hospital staff in the Hunan province of China about the psychological impact of COVID-19. Respondents cited moral and social responsibility as being the strongest driver to continue working long hours during the outbreak and expressed anxiety and concerns regarding their safety, the safety of their families, and high mortality among their patients. Recognition of healthcare staff by hospital management and government, strong infection control guidelines, and specialized equipment and facilities for the management of COVID‑19 were reported as factors that mitigated psychological burnout.