Skip to main content

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.

Search All Content

Search Tips
Save
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Search By Author(s)
Additional Filters
Displaying 41 - 60 of 18399 Results
Poiraud C, Réthoré L, Bourdon O, et al. Infect Dis Now. 2023;53:104641.
Vaccine errors can limit the effectiveness of immunization efforts. Based on survey data from 227 health professionals in France, this study identified several areas for improvement related to knowledge of vaccine-related errors, such as contraindications during pregnancy, vaccine storage, age-related vaccine schedules, and vaccine administration.
Edmonds JK, George EK, Iobst SE, et al. J Obstet Gynecol Neonatal Nurs. 2023;Epub May 10.
Staffing and nursing time at the bedside play a role in missed nursing care. This study focused on the role of COVID-19 on staffing and nursing time at the bedside and, therefore, on missed nursing care in labor and delivery units. During a peak of the pandemic, this study of obstetrics nurses found perceptions of nursing time at the bedside and adequate staffing played a significant role in missed nursing care.

Boston, MA; Betsy Lehman Center; April 2023.

Well-told stories can motivate change. This video translates the experience of Massachusetts patients and family members with medical error for a broad audience. Clinicians also participate and share perspectives on problems in care systems that contribute to patient harm.

Moyal-Smith R, Margo J, Maloney FL, et al. J Patient Saf. 2023;19(4):243-248.

Individual, team, and organizational challenges can hinder the effective implementation of patient safety initiatives. This article describes the development of the Patient Safety Adoption Framework, which includes five domains supporting the adoption and implementation of patient safety initiatives (leadership, culture and context, process, meaningful measurement, and person-centeredness).
Patient Safety Primer May 30, 2023
Anyone can find it challenging to understand medical terms, and millions of Americans have trouble understanding and acting upon health information. The mismatch between individuals' health literacy skills and the complexity of health information and health care tasks involved in managing health has implications on patient safety.

Agency for Healthcare Policy and Research: April 27, 2023.

Ambulatory surgery centers (ASC) experience a variety of error types that can be acerbated by poor safety culture. This webcast provided information on AHRQ’s Surveys on Patient Safety Culture™ (SOPS®) Ambulatory Surgery Center (ASC) Survey, including a review of the SOPS ASC program, survey administration, database submission, and available resources.
Rockville, MD: Agency for Healthcare Research and Quality; October 2020.
Ambulatory surgery centers (ASCs) are increasingly being used to provide surgical care. The AHRQ Surveys on Patient Safety Culture™ (SOPS®) Ambulatory Surgery Center Survey seeks opinions from the field regarding safety culture in the ambulatory surgical center environment. The survey is presented with additional resources to help organizations assess their safety culture, including the results of a pilot program testing the survey and a user's guide. Voluntary data submission will be open June 1-22 for ASCs that have administered the survey.
AHA Training. MetroHealth, Cleveland, OH, June 21-22, 2023.
This education program will present group-focused opportunities for participants to learn how to apply Agency for Healthcare Quality and Research TeamSTEPPS 2.0 curriculum methods to develop staff training and improve team communication in their organizations.

Institute for Healthcare Improvement. September 13 - November 7, 2023.

Root cause analysis (RCA) is a widely recognized retrospective strategy for learning from failure that is challenging to implement. This series of webinars will feature an innovative approach to RCA that expands on the concept to facilitate its use in incident investigations. Instructors for the series will include Dr. Terry Fairbanks and Dr. Tejal K. Gandhi.
Institute for Healthcare Improvement.
This online class prepares individuals to apply for the Institute for Healthcare Improvement patient safety certification program. The on-demand or live sessions cover key patient safety concepts to enhance participants' knowledge about safety culture, systems thinking, leadership, risk identification and analysis, information technology, and human factors. The next online session is August 2-3, 2023.
White VanGompel E, Carlock F, Singh L, et al. J Obstet Gynecol Neonatal Nurs. 2023;52:211-222.
Cesarean delivery can lead to increased maternal morbidity and mortality. In this repeated cross-sectional study, physicians, nurses, and midwives were surveyed about their attitudes towards elective induction of labor before and after results were published from a large, randomized trial (Randomized Trial of Induction Versus Expectant Management, or ARRIVE) supporting elective inductions at 39 weeks to reduce the likelihood of a cesarean. Findings indicate that physician attitudes about induction shifted in favor of induction after ARRIVE, whereas nurse attitudes did not change. Qualitative analyses revealed four themes regarding attitudes towards induction- the importance of timing, identifying who should receive inductions, the need for clear protocols and more staff, and improvements to the induction of labor processes. 
Armstrong AA. J Healthc Qual. 2023;45:125-132.
Healthcare-acquired pressure injuries (HAPI) can result in increased lengths of stay, hospital readmissions, and lower quality of life. This article describes the experience of one hospital which, after it discovered it had higher-than-average HAPI rates, conducted a root cause analysis to determine contributing factors and identify potential solutions. Dedicated nursing staff were hired and trained, and an electronic health record form was developed to document and track HAPI. A root cause analysis was completed for each HAPI to identify trends and implement improvements.
Pugh S, Chan F, Han S, et al. J Nurs Adm. 2023;53:292-298.
The COVID-19 pandemic dramatically impacted the delivery of nursing care. This retrospective analysis examined the impact of a bedside checklist and nursing-led intervention bundle (“Nursing Back to Basics” or NB2B bundle) among patients hospitalized with COVID-19 at one academic hospital in New York City. The NB2B bundle, implemented with a bedside checklist, included five evidence-based interventions. Between March and April 2020, the NB2B intervention showed a 12% reduction in mortality due to COVID-19 compared with usual care.
Hyvämäki P, Sneck S, Meriläinen M, et al. Int J Med Inform. 2023;174:105045.
Insufficient or incorrect transfer of patient information, whether caused by human or organizational factors, can result in adverse events during transitions of care. This study used four years of incident reports to identify the types, causes, and consequences of health information exchange- (HIE) related patient safety incidents in emergency care, (ED) emergency medical services (EMS), or home care. The two main kinds of HIE-related incidents were (1) inadequate documentation and inadequate use of information (e.g., deficiencies in content), and (2) causes related to the health professional or organization; consequences were adverse events or additional actions to prevent, avoid, and correct adverse events.

Salvon-Harman J. Healthcare Executive. 2023;39(3):48-49.

A strong safety work environment is core to reliable care delivery and staff wellbeing. This article discusses how leadership should listen broadly, embody accountability, support disclosure, and build trust to build a robust safety culture.
Arnal-Velasco D, Heras-Hernando V. Curr Opin Anaesthesiol. 2023;36:376-381.
The Safety II framework and organizational resilience both focus on what goes right in healthcare and adjusting to disturbances through anticipation, monitoring, responding, and learning. This narrative review highlights recent research conducted within a Safety II and resilience framework such as Learning from Excellence and debriefing "what went right" after simulation training. The authors suggest learning from errors or what goes right should be reframed simply as learning.
Riblet NB, Soncrant C, Mills PD, et al. Mil Med. 2023;Epub Mar 31.
Patient suicide is a sentinel event, and suicide among veterans has gained attention. In this retrospective analysis of suicide-related events reported to the Veterans Health Administration (VHA) National Center for Patient Safety between January 2018 and June 2022, researchers found that deficiencies in mental health treatment, communication challenges, and unsafe environments were the most common contributors to suicide-related events.

Massachusetts Protection and Advocacy. Boston, MA:  Disability Law Center; May 8, 2023.

Behavioral health patients present unique challenges in their care that can contribute to unintended harm. The analysis examines a delayed diagnosis, referral, and treatment of skin cancer that contributed to the death of a patient. Suggestions for improvement included conducting a root cause analysis to identify systemic problems, use of photography to track skin lesion progression, and implementation of a warm handoff process to improve staff communication.
Wiegand AA, Sheikh T, Zannath F, et al. BMJ Qual Saf. 2023;Epub May 10.
Sexual and gender minority (SGM) patients may experience poor quality of healthcare due to stigma and discrimination. This qualitative study explored diagnostic challenges and the impact of diagnostic errors among 20 participants identifying as sexual minorities and/or gender minorities. Participants attribute diagnostic error to provider-level and personal challenges and how diagnostic error worsened health outcomes and led to disengagement from healthcare. The authors of this article also summarize patient-proposed solutions to diagnostic error through the use of inclusive language, increasing education and training on SGM topics, and inclusion of more SGM individuals in healthcare.