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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 21 - 40 of 18733 Results
Choi JJ, Rosen MA, Shapiro MF, et al. Diagnosis (Berl). 2023;Epub Aug 11.
Teamwork is increasingly seen as an important component of diagnostic excellence. Through a systematic review and observations of team dynamics in a hospital medical ward, researchers identified three areas requiring additional research- (1) team structure, (2) contextual factors, and (3) emergent states (e.g., shared mental models).
Samuelson-Kiraly C, Mitchell JI, Kingston D, et al. Healthc Manage Forum. 2023;Epub Aug 30.
The threat of cybersecurity risks to patient safety is receiving increasing attention. This article describes the development of a new standard to support cyber resiliency in Canada’s healthcare system. The guidance addresses key areas of concern (e.g., organizational risk management, technology considerations, contingency planning), provides suggested roles and responsibilities for an organizational cybersecurity team, and emphasizes the importance of cyber incident response planning.

Peterson M. Los Angeles Times. September 5, 2023.

Safe practice in community pharmacy is challenged by production pressure, workforce shortages, and multitasking. This story examined the mistakes made at major retail pharmacy chains in California. It provides examples perpetrated across the industry to target universal areas of needed improvement and potential strategies to address them.

The Daisy Foundation and Institute for Healthcare Improvement.

Nurses have a fundamental role in safe care delivery by fostering a healthy work environment. This award recognizes nurses that exhibit compassion, patient and family centeredness, and a commitment to workplace safety. The award will be presented at annual IHI Patient Safety Congress. The award nomination process for 2023 closes on December 3.

Rockville, MD: Agency for Healthcare Research and Quality: September 2023.

Patient safety progress is dynamic, consistently producing evidence for application to generate improvements. This report is the fourth in a series funded by the Agency for Healthcare Research and Quality to track a prioritized set of emerging and existing safety approaches to confirm their value and effectiveness. This report will be compiled as new conclusions are formulated. Each review will be posted to the collection as they are completed. The first three Making Healthcare Safer reports, published in 2001, 2013, and 2020, have each served as a consolidated evidence source for clinicians, health system leadership, researchers, and government agencies. Chapter protocols and the results of an examination of harms associated with video-based telehealth are now available. 
Bell SK, Harcourt K, Dong J, et al. BMJ Qual Saf. 2023;Epub Aug 21.
Patient and family engagement is essential to effective and safe diagnosis. OurDX is a previsit online engagement tool to help identify opportunities to improve diagnostic safety in patients and families living with chronic conditions. In this study, researchers implemented OurDX in specialty and primary care clinics at two academic healthcare organizations and examined the potential safety issues and whether patient/family contributions were integrated into the post-visit notes. Qualitative analysis of 450 OurDX reports found that participants contributed important information about the diagnostic process. Participants with diagnostic concerns were more likely to raise concerns about the diagnostic process (e.g., access barriers, problems with tests/referrals, communication breakdowns), which may represent diagnostic blind spots.
Yartsev A, Yang F. Simul Healthc. 2023;18:279-282.
Intensive care units (ICUs) are complex care environments at high risk for medical errors. In this retrospective study, researchers identified the occurrence of common ICU scenarios and skills during code blue events and measured trainees’ self-reported confidence in these skills. The analysis found that more than 25% of trainees reported low levels of confidence in three scenarios – familiarity with the advanced life support trolley, electrocardiogram strip interpretation, and operation of an external defibrillator. This process of integrating critical incident data with trainee self-assessment can be generalized to other clinical scenarios to create targeted education and simulation curriculum.
Brown CE, Snyder CR, Marshall AR, et al. J Gen Intern Med. 2023;Epub Aug 24.
Structural racism continues to perpetuate health disparities. As part of their study on how black patients with serious illness experience racism from providers, researchers conducted interviews with 21 providers to understand ways they address anti-Black racism in their practice. Providers felt unprepared to address racism with their patients, wanted to provide tools for patients to bring up their experiences while also acknowledging the additional burden this would place on Black patients, and thought patient- and provider-facing programs could facilitate discussions. Additionally, despite extensive research on the negative impacts of structural racism on health, participants cited the need for more data.
Magerøy MR, Braut GS, Macrae C, et al. BMC Health Serv Res. 2023;23:880.
Ensuring staff have a safe work environment and patients receive safe care are separate but complementary goals. This study describes how elected politicians and healthcare leaders balance workplace safety regulations and patient quality and safety goals in long-term care facilities. Tensions between the groups were identified (e.g., where leaders see flexibility, elected leaders see vagueness). Study themes include creating and improving channels for communication, and clear delineation of roles and responsibilities.
Wallin A, Ringdal M, Ahlberg K, et al. Scand J Caring Sci. 2023;37:414-423.
Numerous factors can hinder safe radiology practices, such as communication failures and image interpretation errors. Based on semi-structured interviews with 17 radiologists in Sweden, this study identified 20 themes at the individual-, organization-, technology-, task-and environment-levels describing factors supporting patient safety in radiology. Factors described by participants included the use of standardized tools and work routines (e.g., checklists), handoffs, and incident reporting systems.
Rao A, Pang M, Kim J, et al. J Med Internet Res. 2023;25:e48659.
Interest in testing ChatGPT as a clinical tool is increasing. This study asked ChatGPT to provide a differential diagnosis, diagnostic testing, final diagnosis, and care management for 36 previously published clinical vignettes. ChatGPT had an overall accuracy of 72%, with the highest level of accuracy at the final diagnosis stage (77%).

Zucchelli G, Stefanini M, eds. Periodontol 2000. 2023;92(1):1-398.

Patient safety in dentistry shares common challenges with medicine and their emergence in a distinct care environment. This special issue covers a range of adverse events and treatment mistakes associated with periodontal procedures. Topics examined include human factors, implant placement and methodologic bias.
Hose B-Z, Carayon P, Hoonakker PLT, et al. Appl Ergon. 2023;113:104105.
Health information technology (IT) usability continues to be a source of patient harm. This study describes the perspectives of a variety of pediatric trauma team members (e.g., pediatric emergency medicine attending, surgical technician, pediatric intensive care unit attending) on the usability of a potential team health IT care transition tool. Numerous barriers and facilitators were identified and varied across department and role.
Seys D, Panella M, Russotto S, et al. BMC Health Serv Res. 2023;23:816.
Clinicians who are involved in a patient safety incident can experience psychological harm. This literature review of 104 studies identified five levels of support that can be provided to healthcare workers after a patient safety incident – (1) prevention, (2) self-care of individuals and/or teams, (3) support by peers and triage, (4) structured professional support, and (5) structured clinical support.
Michelson KA, Bachur RG, Grubenhoff JA, et al. J Emerg Med. 2023;65:e9-e18.
Missed diagnosis in the emergency department can result in unplanned hospitalization due to complications from worsening symptoms. In this study, pediatric patients with and without missed emergency department diagnosis were compared to determine differences in outcomes and hospital utilization. Children with missed diagnosis of appendicitis or new-onset diabetic ketoacidosis experienced more complications, hospital days and readmissions; there was no difference for sepsis diagnosis.

ECRI. ECRI Headquarters, Plymouth Meeting, PA, October 11-12, 2023. 9:00 AM – 4:45 PM (eastern).

Human factors engineering (HFE) is a core approach to improving the reliability and safety of complex practice. This conference will provide direction in understanding how to proactively define risks and design processes to reduce the potential for failure.
Ryan SL, Logan M, Liu X, et al. Jt Comm J Qual Patient Saf. 2023;Epub Jul 31.
I-PASS is a structured tool to improve handoffs and communication between clinicians and promote patient safety. This study examined I-PASS implementation practices over a six-year period in 10 departments at one large academic medical center. Researchers found that most clinical services successfully implemented I-PASS and those using I-PASS conducted the most efficient handovers.

Subgroup on Patient Safety. Washington DC: President’s Council of Advisors on Science and Technology; September 2023.

The President’s Council of Advisors on Science and Technology brings together topic experts to summarize important issues for the consideration of the President of the United States. This report introduces the persistent problem of unsafe care and recommends a federal leadership entity, application of evidence-based solutions, true patient partnership and research funding as avenues to achieve stable improvement.
Harada Y, Watari T, Nagano H, et al. Diagnosis. 2023;Epub Aug 10.
Atypical presentation of common conditions or typical presentation or rare conditions may result in delayed diagnosis and treatment. This article uses 560 case reports to classify contributing factors to diagnostic errors in rare conditions and/or atypical presentations of common conditions. The results indicate that for less common and more atypical conditions, failure or delay in considering the final diagnosis becomes an increasingly important contributor to diagnostic error.
Stærk M, Lauridsen KG, Johnsen J, et al. Resusc Plus. 2023;14:100410.
In situ simulation is a valuable tool to identify latent safety threats. In this study, 36 unannounced in situ in-hospital cardiac arrest (IHCA) simulations were conducted across 4 hospitals and identified 30 system errors. Errors were categorized as involving human, organization, hardware, or software errors. These system errors contributed to treatment delays and care omissions.