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Rockville, MD: Agency for Healthcare Research and Quality.
In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. The 2021 report highlights that a wide range of quality measures have shown improvement in quality, access, and cost.

Rockville, MD: Agency for Healthcare Research and Quality. January 12, 2022.

An organization’s understanding of its culture is foundational to patient safety. This webinar introduced the AHRQ Surveys on Patient Safety Culture™ (SOPS®) program. The session covered the types of surveys available and review resources available to best use the data to facilitate conversations and comparisons to inform improvement efforts. 
Buljac-Samardzic M, Dekker-van Doorn C, van Wijngaarden JDH. J Patient Saf. 2021;17:490-496.
Emotional exhaustion and burnout among healthcare workers can jeopardize patient safety. This survey of caregivers from two long-term care organizations found that psychological detachment – the ability to separate oneself from the job and focusing on other areas of life – positively affects patient safety and may contribute to less burnout.
Liukka M, Hupli M, Turunen H. Leadersh Health Serv (Bradf Engl). 2021;34:499-511.
The Hospital Survey on Patient Safety Culture and Nursing Home Survey on Patient Safety Culture were used in one Finish healthcare organization to assess 1) differences in employee perceptions of safety culture in their respective settings, and 2) differences between professionals’ and managers’ views. Managers assessed safety culture higher than professionals in both settings. Acute care patient safety scores were significantly positive in 8 out of twelve domains, compared to only one in long-term care.
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
Quach ED, Kazis LE, Zhao S, et al. BMC Health Serv Res. 2021;21:842.
The safety climate in nursing homes influences patient safety. This study of frontline staff and managers from 56 US Veterans Health Administration community living centers found that organizational readiness to change predicted safety climate. The authors suggest that nursing home leadership explore readiness for change in order to help nursing homes improve their safety climate.
Damery S, Flanagan S, Jones J, et al. Int J Environ Res Public Health. 2021;18:7581.
Hospital admissions and preventable adverse events, such as falls and pressure ulcers, are common in long-term care. In this study, care home staff were provided skills training and facilitated support. After 24 months, the safety climate had improved, and both falls and pressure ulcers were reduced.
Serre N, Espin S, Indar A, et al. J Nurs Care Qual. 2022;37:188-194.
Safety concerns are common in long-term care (LTC) facilities. This qualitative study of LTC nurses explored nurses’ experiences managing patient safety incidents (PSI). Three categories were identified: commitment to resident safety, workplace culture, and emotional reaction. Barriers and facilitators were also discussed.

Rockville, MD: Agency for Healthcare Research and Quality; June 2021.

The use of antibiotics should be monitored to reduce the potential for infection in care facilities. This toolkit outlines offers a methodology for launching or invigorating an antibiotic stewardship program. Designed to align with four time elements of antibiotic therapy, its supports processes that enable safety for nursing home residents.
Guo W, Li Y, Temkin-Greener H. J Am Med Dir Assoc. 2021;22:2384-2388.e1.
This study examined the association between patient safety culture (PSC) and community discharge of long-term care (LTC) residents.  Results show that two domains of PSC- teamwork and supervisor expectations and actions regarding patient safety- are significantly associated with increased likelihood of discharge to a community setting. Focusing on these domains to improve patient safety culture may also increase community discharge rates. 
Goh HS, Tan V, Chang J, et al. J Nurs Care Qual. 2021;36:e63-e68.
Incident reporting systems are a common method for hospitals to detect patient safety events, but prior research has questioned whether these systems improve outcomes. Conducted in a nursing home, this study found that an existing incident reporting system redesigned to facilitate double-loop learning could improve nurses’ patient safety awareness and workplace practices, which could improve patient outcomes and safety.
Orth J, Li Y, Simning A, et al. Gerontologist. 2021;61:1296-1306.
Nursing home patient safety culture is associated with healthcare quality and patient outcomes. This large cross-sectional study of nursing homes in the United States found that speaking-up behavior and communication openness were associated with a decreased risk of in-residence death among older adults with dementia. This association was strong in nursing homes located in states with higher nursing home nurse staffing requirements.  

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.
Braithwaite J, Vincent C, Garcia-Elorrio E, et al. BMC Med. 2020;18:340.
Delivering high-quality, safe healthcare requires coordination and integration of complex systems and activities. The authors propose three initiatives to further practical opportunities for transforming health systems across the world – a country-specific blueprint for change, tangible steps to reduce inequities within and across health systems, and learning from both errors and successes to improve safe care delivery.  
Temkin-Greener H, Cen X, Li Y. Gerontologist. 2020;60:1303-1311.
Nurse staffing is an important factor in maintaining patient safety. In this study, the Nursing Home Survey on Patient Safety Culture was used to assess the association of registered nurse (RN) and certified nurse assistant (CNA) turnover on perceived patient safety culture. Results indicate that CNA turnover is associated with lower patient safety culture scores, but RN turnover is not. The authors conclude that patient safety culture improvements in nursing homes may be dependent on retaining a well-trained and skilled nursing staff.