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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 11394 Results
Sederstrom N, Lasege T. Hastings Cent Rep. 2022;52:s24-s29.
Racial bias and systemic racism in healthcare are increasingly seen as critical patient safety issues. This commentary discusses the relationship between medical ethics and racism in healthcare institutions, using examples such as racial biases in clinical tools and algorithms, the effect of racial bias on diagnosis and diagnostic error, and how excess disease burden can be viewed as proxy for racism.
Braun EJ, Singh S, Penlesky AC, et al. BMJ Qual Saf. 2022;31:716-724.
Early warning systems (EWS) use patient data from the electronic health record to alert clinicians to potential patient deterioration. Twelve months after a new EWS was implemented in one hospital, nurses were interviewed to gather their perspectives on the program experience, utility, and implementation. Six themes emerged: timeliness, lack of accuracy, workflow interruptions, actionability of alerts, underappreciation of core nursing skills, and opportunity cost.
Buhlmann M, Ewens B, Rashidi A. J Adv Nurs. 2022;78:2960-2972.
The term “second victims” describes clinicians who experience emotional or physical distress following involvement in an adverse event. Nurses and midwives were interviewed about “moving on” from the impact of a critical incident. Five main themes were identified: Initial emotional and physical response, the aftermath, long-lasting repercussions, workplace support, and moving on. Lack of organizational support exacerbated the nurses’ and midwives’ responses.
Lim L, Zimring CM, DuBose JR, et al. HERD. 2022;15:28-41.
Social distancing policies implemented during the COVID-19 pandemic challenged healthcare system leaders and providers to balance infection prevention strategies and providing collaborative, team-based patient care. In this article, four primary care clinics made changes to the clinic design, operational protocols, and usage of spaces. Negative impacts of these changes, such as fewer opportunities for collaboration, communication, and coordination, were observed.
MacLeod JB, D’Souza K, Aguiar C, et al. J Cardiothorac Surg. 2022;17:69.
Post-operative complications can lead to increased length of hospital stay, cost, and resource utilization. This retrospective study compared “fast track” patients (patients extubated and transferred from ICU to a step-down unit the same day as their procedure) and patients who were not fast tracked. Results showed fast track pathways led to a reduction in ICU and overall hospital length of stay and similar post-operative outcomes.
Morsø L, Birkeland S, Walløe S, et al. Jt Comm J Qual Patient Saf. 2022;48:271-279.
Patient complaints can provide insights into safety threats and system weaknesses. This study used the healthcare complaints analysis tool (HCAT) to identify and categorize safety problems in emergency care. Most problems arose during examination/diagnosis and frequently resulted in diagnostic errors or errors of omission.
Ong N, Long JC, Weise J, et al. J Appl Res Intellect Disabil. 2022;35:675-690.
Children with intellectual disabilities can be at higher risk for patient safety events and poor-quality care. This systematic review and thematic analysis identified several themes (e.g., distress, communication, training, and education) underscoring healthcare staff experiences in providing care for pediatric patients with intellectual disabilities. The review found that healthcare staff feel they lack necessary skills to provide care for children with intellectual disabilities and have difficulties communicating effectively with both patients and their parents.
Redley B, Taylor N, Hutchinson AM. J Adv Nurs. 2022;78:3710-3720.
Nurses play a critical role in reducing preventable harm among inpatients. This cross-sectional survey of nurses working in general medicine wards identified both enabling factors (behavioral regulation, perceived capabilities, and environmental context/resources) and barriers (intentions, perceived consequences, optimism, and professional role) to implementing comprehensive harm prevention programs for older adult inpatients.
Tan J, Krishnan S, Vacanti JC, et al. J Healthc Risk Manag. 2022;42:9-14.
Inpatient falls are a common patient safety event and can have serious consequences. This study used hospital safety reporting system data to characterize falls in perioperative settings. Falls represented 1% of all safety reports between 2014 and 2020 and most commonly involved falls from a bed or stretcher. The author suggests strategies to identify patients at high risk for falls, improve fall-related training for healthcare personnel, and optimize equipment design in perioperative areas to prevent falls.
Ulmer FF, Lutz AM, Müller F, et al. J Patient Saf. 2022;18:e573-e579.
Closed-loop communication is essential to effective teamwork, particularly during complex or high-intensity clinical scenarios. This study found that participation in a one-day simulation team training for pediatric intensive care unit (PICU) nurses led to significant improvements in closed-loop communication in real-life clinical situations.

The Collaborative for Accountability and Improvement. May 19, 2022. 

The sharing of stories is a key approach for providing information and context to promote change. This webinar focused on stories drawn from lawsuits, the general patient and family motivation of legal action to minimize the repetition of similar errors, and the ironies involved in the adherence to legal confidentiality that can reduce learning from error.
Sosa T, Galligan MM, Brady PW. J Hosp Med. 2022;17:199-202.
Situation awareness supports effective teamwork and safe care delivery. This commentary highlights the role of situation awareness in watching the condition of pediatric inpatients to reduce instances of unrecognized clinical deterioration. It features rapid response models enhanced by event review, psychological safety, and patient and family partnering as mechanisms improved through situation awareness.

Rockville, MD; Agency for Healthcare Research and Quality: April 2022.

TeamSTEPPS promotes effective teamwork, collaboration, and communication in health care while focusing on strategies known to improve patient safety. This challenge competition seeks submissions to revise existing TeamSTEPPS videos to improve health literacy, equity, and cultural sensitivity. 

Kelman B. Kaiser Health News. April 29, 2022.

Technological solutions harbor unique risks that can result in patient harm. This article shares a response to reports of automated dispensing cabinet (ADC) menu selection limitations that contribute to mistakes. The piece suggests the implementation of a 5-letter search requirement prior to removing a medication from an ADC. It provides an update on industry response to this forcing function recommendation.

Institute for Safe Medication Practices and the Just Culture Company. May 6, 2022.

Organizational factors can contribute to the occurrence of patient safety events and how health systems respond to such events. This webinar highlighted lessons learned in the aftermath of a fatal medication error, and strategies to improve patient safety at the organizational level through system design and accountability.
Davidson C, Denning S, Thorp K, et al. BMJ Qual Saf. 2022;31:670-678.
People of color experience disproportionately higher rates of maternal morbidity and mortality. As part of a larger quality improvement and patient safety initiative to reduce severe maternal morbidity from hemorrhage (SMM-H), this hospital analyzed administrative data stratified by race and ethnicity, and noted a disparity between White and Black patients. Review of this data was integrated with the overall improvement bundle. Post-implementation results show that SMM-H rates for Black patients decreased.
Díez R, Cadenas R, Susperregui J, et al. Int J Environ Res Public Health. 2022;19:4313.
Older adults living in nursing homes are at increased risk of polypharmacy and its associated adverse outcomes, such as drug-drug interactions. The medication records of 222 older adult residents of one Spanish nursing home were screened for potential drug-drug adverse events. Nearly all included residents were taking at least one potentially inappropriate medication, and drug-drug interactions were common.
Enumah SJ, Resnick AS, Chang DC. PLOS ONE. 2022;17:e0266696.
While quality and patient safety initiatives are implemented to improve patient outcomes, they also typically include a financial cost which must be balanced with expected outcomes. This study compared hospitals’ financial performance (i.e., financial margin and risk of financial distress) and outcomes (i.e., 30-day readmission rates, patient safety indicator-90 (PSI-90)) using data from the American Hospital Association and Hospital Compare. Hospitals in the best quintiles of readmission rates and PSI-90 scores had higher operating margins compared to the lowest rated hospitals.
Gilbert GL, Kerridge I. BMC Health Serv Res. 2022;22:504.
Hospital transmission of COVID-19 has necessitated review of organization infection prevention and control (IPC) policies and practices. This study, conducted before the pandemic, compared IPC attitudes and practices of nurses and physicians, and how these differences affect interpersonal relationships. Both professions described unflattering and stereotypical behaviors of the other (i.e., doctors are unaware or disdainful of IPC; “bossy” nurses).  Many IPC policies implemented during the pandemic, such as encouraging all healthcare workers to speak up about infection prevention breaches, were accepted by both professions, and the authors recommend seizing on this interprofessional unity to continue adherence to all IPC policies.
Kuske S, Willmeroth T, Schneider J, et al. BMJ Open Qual. 2022;11:e001741.
Comprehensive implementation of reporting and learning systems (RLS, also known as incident reporting systems) is important for its successful use as a patient safety improvement tool. This study aimed to develop a set of “implementation patient safety indicator(s) sets” to monitor the extent to which an RLS has been implemented in hospitals. Implementation outcomes include acceptability, adoption, appropriateness, implementation costs, feasibility, fidelity, penetration, and sustainability. Study participants rated acceptability and sustainability as most relevant to successful implementation.