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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 61 - 80 of 18399 Results
Jeffries M, Salema N-E, Laing L, et al. BMJ Open. 2023;13:e068798.
Clinical decision support (CDS) systems were developed to support safe medication ordering, alerting prescribers to potential unsafe interactions such as drug-drug, drug-allergy, and dosing errors. This study uses a sociotechnical framework to understand the relationship between primary care prescribers’ safety work and CDS. Prescribers described the usefulness of CDS but also noted alert fatigue.

Patel J. PM Healthcare Journal. Spring 2023(4):5-18.

Language discordance is known to degrade medication safety. The article discusses an examination of English pharmacists’ reactions and responses to language barriers with patients. The results highlight the need for improved training and support for pharmacists to effectively dispense medications and counsel patients with whom they don’t share a common language.
Cohen TN, Berdahl CT, Coleman BL, et al. J Nurs Care Qual. 2023;Epub May 9.
Institutional error and near-miss reporting helps identify systemic weaknesses and areas for improvement. COVID-19 presented a unique environment to study error reporting during organizationally stressful times. In this study, incident reports of medication errors or near misses during a COVID-19 surge were analyzed. Skill-based (e.g., forgetting to administer a dose) and communication errors were the most common medication safety events.
Shahrestanaki SK, Rafii F, Najafi Ghezeljeh T, et al. BMC Health Serv Res. 2023;23:467.
Home care settings have unique patient safety challenges. This qualitative study including home care clinicians, inspectors, and family caregivers in Iran highlights that the healthcare team plays an important role in creating and promoting safe home care, including the use of individual risk assessments and mitigation of risk factors.
Folcarelli P, Hoffman J, Janes M, et al. J Healthc Risk Manag. 2023;Epub May 2.
Hospital mergers may improve some safety outcomes but also present challenges. This commentary describes how a third-party proactive risk assessment, ideally prior to the merger, can identify strengths and weaknesses of the organizations' safety cultures. The article describes an insurer-directed assessment, but other resources are also available, such as from the Institute for Healthcare Improvement National Action Plan.
Kepner S, Bingman C, Jones RM. Patient Saf. 2023;Epub Apr 28.
Healthcare-associated infections remain a patient safety issue at long-term care facilities. Based on incident data from the Pennsylvania Patient Safety Reporting System (PA-PSRS), this analysis found that healthcare-associated infections in long-term care settings increased by 12.5% between 2021 and 2022; over half of this increase is due to an increase in respiratory and gastrointestinal infections.

Epsom and St Helier University Hospitals. Epsom, UK: National Health Service; March 21, 2023.

The Systems Engineering Initiative for Patient Safety (SEIPS) framework is an established human factors-based approach to designing care system improvements. This video introduces the concepts behind SEIPS and uses an everyday non-clinical activity to illustrate its use for a broad audience to identify problems.
Duffy C, Menon N, Horak D, et al. J Patient Saf. 2023;19:281-286.
Resiliency and proactive safety behaviors can improve safety in the perioperative environment. In this article, the authors describe safety attitudes of perioperative staff after participating in a proactive activity, One Safe Act (OSA). Most participants reported the OSA activity would change their work practices, improve their work unit's ability to deliver safe care, and demonstrate their colleagues' commitment to patient safety.
Weiss M, Morrison EW, Szyld D. Front Psychol. 2023;14:1129359.
Psychological safety and willingness to speak up about safety concerns are cornerstone to safety culture. Using four clinical vignettes that described the same case in the Emergency Department but differed with respect to whether a nurse spoke up with treatment-related concerns or remained silent, researchers examined healthcare team members’ perspectives of psychological safety and discussed the importance of organizational and team leadership that encourages and supports speaking up behaviors.
Fillo KT, Saunders K. Bureau of Health Care Safety and Quality, Department of Public Health. Boston, MA: Commonwealth of Massachusetts; 2023.
This reoccurring report compiles patient safety data collected by Massachusetts hospitals. The 2022 numbers document an increase in serious reportable events recorded in acute care hospitals, from 1430 the previous year to 1632. This presentation also includes events from ambulatory surgery centers. Older reports are also available.

Bryant A. UpToDate. May 18, 2023.

Implicit bias is progressively being discussed as a detractor to safe health care by fostering racial and ethnic inequities. This review examines the history of health inequities at the patient, provider, health care system, and cultural levels in obstetric and gynecologic care. It shares actions documented in the evidence base for application in health care to reduce the impact of implicit bias, with an eye toward maternal care
Institute for Healthcare Improvement. September 13 - November 21, 2023.
Burnout among health care workers negatively affects system improvement. This webinar series will highlight strategies to establish a healthy work environment that strengthens teamwork, staff engagement, and resilience. Instructors include Dr. Donald Berwick and Derek Feeley.
Rainer T, Lim JK, He Y, et al. Hosp Pediatr. 2023;13:461-470.
Structural racism and implicit biases can affect clinical judgement and impede the delivery of effective mental health care. Based on a case of an adolescent Black girl navigating through the pediatric behavioral health system, this article discusses how structural racism and health disparities in behavioral health care contributed to misdiagnosis and poor care. The authors outline several actions at the structural, institutional, and interpersonal levels to address racism’s impact on pediatric mental and behavioral healthcare.
Machen S. BMJ Open Qual. 2023;12:e002020.
Learning from patient safety incidents can help health care organizations improve processes and care delivery. This article provides a template for organizations to review patient safety incidents and classify them into themes from a human factors and systems thinking perspective. The process involves clearly characterizing the safety incidents, describing the involved safety systems, identifying and classifying contributing factors, completion of narrative analysis to identify commonalities and differences in the way contributing factors affect the incidents, and identification of safety recommendations. 
Detollenaere J, Van Ingelghem I, Van den Heede K, et al. Eur J Pediatr. 2023;Epub Apr 3.
The hospital-at-home (HAH) model allows patients to receive hospital-level care in their homes. This systematic review identified 25 articles (18 interventions) comparing outcomes of pediatric HAH care to standard in-hospital care. Hospital at home was not associated with increased hospital readmissions or adverse events. However, the quality of the studies was low to very low, and additional high-quality research is required.

National Action Alliance. June 27, 2023. 2:00- 3:00 PM (eastern)

Violence in the health care environment detracts from staff and clinician ability to provide safe care. Sponsored by the Centers for Disease Control and Prevention, this webinar will discuss the importance of violence prevention.

Freedman DH.  Newsweek Magazine. May 12, 2023.

The unintended consequences of reductions in access to prescription opioids can result in poor addiction care and ineffective pain management. This article discusses precursors to the system failure affecting these patients and treatment options that work given access and supply constraints.

Farnborough, UK: Healthcare Safety Investigation Branch; April 2023.

Misattribution of child maltreatment injuries can be a serious misdiagnosis affecting families and patients. This report analyzes ten safety incident reports from across the British National Health Service to explore how non-accidental injury was missed. Themes identified as contributing to the problems include lack of information sharing, inconsistent guidance, and emergency department care demands.

Weintraub K. USA Today. May 3, 2023.

The semi-annual Leapfrog Hospital Safety Grades are recognized across the industry as a tool for highlighting successes and tracking gaps in safety to focus improvement efforts. This article shares one organization’s work to improve core safety activities related to medication safety, falls, infections, and hand hygiene.