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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 28 Results
De Micco F, Fineschi V, Banfi G, et al. Front Med (Lausanne). 2022;9:901788.
The COVID-19 pandemic led to a significant increase in the use of telehealth. This article summarizes several challenges that need to be addressed (e.g., human factors, provider-patient relationships, structural, and technological factors) in order to support continuous improvement in the safety of health care delivered via telemedicine.
Fawzy A, Wu TD, Wang K, et al. JAMA Intern Med. 2022;182:730-738.
Black and brown patients have experienced disproportionately poorer outcomes from COVID-19 infection as compared with white patients. This study found that patients who identified as Asian, Black, or Hispanic may not have received timely diagnosis or treatment due to inaccurately measured pulse oximetry (SpO2). These inaccuracies and discrepancies should be considered in COVID outcome research as well as other respiratory illnesses that rely on SpO2 measurement for treatment.
Fakih MG, Bufalino A, Sturm L, et al. Infect Control Hosp Epidemiol. 2021;43:26-31.
Central line-associated blood steam infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) prevention were an important part of patient safety prior to the COVID-19 pandemic. This study compared CLABSI and CAUTI rates in 78 hospitals during the 12-month period prior to the pandemic and the first 6 months of the pandemic. CLABSI rates increased by 51% during the pandemic period, mainly in the ICU. CAUTI rates did not show significant changes.
Ellis R, Hardie JA, Summerton DJ, et al. Surg. 2021;59:752-756.
Many non-urgent, non-cancer surgeries were postponed or canceled during COVID-19 surges resulting in a potential loss of surgeons’ “currency”. This commentary discusses the benefits of, and barriers to, dual surgeon operating as a way to increase currency as elective surgeries are resumed.
Taylor M, Reynolds C, Jones RM. Patient Safety. 2021;3:45-62.
Isolation for infection prevention and control – albeit necessary – may result in unintended consequences and adverse events. Drawing from data submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS), researchers explored safety events that impacted COVID-19-positive or rule-out status patients in insolation. The most common safety events included pressure injuries or other skin integrity events, falls, and medication-related events.
Dhahri AA, Refson J. BMJ Leader. 2021;5:203-205.
Hierarchy and professional silos can disrupt collaboration. This commentary describes one hospital’s approach to shifting the surgical leadership role to facilitate communication and cross-organizational influence to affect quality and safety performance.
Kakemam E, Chegini Z, Rouhi A, et al. J Nurs Manag. 2021;29:1974-1982.
Clinician burnout, characterized by emotional exhaustion, depersonalization, and decreased sense of accomplishment, can result in worse patient safety outcomes. This study explores the association of nurse burnout and self-reported occurrence of adverse events during COVID-19. Results indicate higher levels of nurse burnout were correlated with increased perception of adverse events, such as patient and family verbal abuse, medication errors, and patient and family complaints. Recommendations for decreasing burnout include access to psychosocial support and human factors approaches.
Della Torre V, E. Nacul F, Rosseel P, et al. Anaesthesiol Intensive Ther. 2021;53:265-270.
Human factors (HF) is the interaction between workers, equipment, and the environment. The COVID-19 pandemic has accelerated the adoption of HF in intensive care units across the globe. This paper expands on the core concepts of HF and proposes the additional key concepts of agility, serendipity, innovation, and learning. Adoption of these HF concepts by leadership and staff can improve patient safety in intensive care units in future pandemics and other crisis situations.
Panda N, Etheridge JC, Singh T, et al. World J Surg. 2021;45:1293-1296.
The World Health Organization (WHO) surgical safety checklist is widely used in surgical settings to prevent errors. This multinational panel representing multiple clinical specialties identified 16 recommendations for checklist content modification and implementation during the COVID-19 pandemic. These recommendations exemplify how the checklist can be adapted to meet urgent and emerging needs of surgical units by targeting important processes and encouraging critical discussions.

La Regina M, Tanzini M, Venneri F, et al for the Italian Network for Health Safety. Dublin, Ireland: International Society for Quality in Health Care; 2021.

The COVID-19 pandemic is a rapidly evolving situation that requires a system orientation to diagnosis, management and post-acute care to keep clinicians, patients, families and communities safe. This set of recommendations is anchored on a human factors approach to provide overarching direction to design systems and approaches to respond to the virus. The recommendations focus on team communication and organizational culture; the diagnostic process; patient and family engagement to reduce spread; hospital, pediatric, and maternity processes and treatments; triage decision ethics; discharge communications; home isolation; psychological safety of staff and patients, and; outcome measures. An appendix covers drug interactions and adverse effects for medications used to treat this patient population. The freely-available full text document will be updated appropriately as Italy continues to respond, learn and amend its approach during the outbreak.

Toccafondi G, Di Marzo F, Sartelli M, et al. Int J Qual Health Care. 2021;33(Supp 1):51-55. 

 

The impact of the COVID-19 pandemic on infection prevention efforts and healthcare-associated infections is unclear. This article discusses how the COVID-19 pandemic has led to adaptations to infection prevention and control and surveillance (IPCS) practices and a human factors and ergonomics perspective in surgery. Leveraging lessons learned from the pandemic, the authors use a human factors perspective to propose an enhanced infection prevention and control approach to prevent surgical site infections. 
Britton CR, Hayman G, Stroud N. J Perioper Pract. 2021;31:44-50.
The COVID-19 pandemic has highlighted the crucial role that team and human factors play in healthcare delivery. This article describes the impact of a human factors education and training program focused on non-technical skills and teamwork (the ONSeT project) – on operating room teams during the pandemic. Results indicate that the project improved team functioning and team leader responsiveness.
Alagha MA, Jaulin F, Yeung W, et al. J Patient Saf. 2021;17:87-89.
This article uses an adapted human factors analysis classification system (HFACS) to describe three levels of failure occurring during the COVID-19 pandemic: organizational factors (e.g., resource management, organizational climate), individuals and their environments (e.g., lack of training in  personal protective equipment (PPE) donning), and supervision factors (such as those caused by staffing shortages).
Sjoding MW, Dickson RP, Iwashyna TJ, et al. N Engl J Med. 2020;383:2477-2478.
Pulse oximetry is used to triage patients, initiate or adjust oxygen administration, and, more recently, as a way to remotely monitor COVID-19 patients at home. However, a study in the Johns Hopkins Health System showed that Asian, Black, or Hispanic patients are more likely to experience inaccurate readings, potentially resulting in missed or delayed diagnosis of respiratory diseases. This study used paired oxygen saturation by pulse oximetry and arterial oxygen saturation in arterial blood gas in Black and white patients before and during the COVID-19 pandemic. Consistent with the Johns Hopkins study, Black patients had three times the frequency of occult hypoxia than white patients.
Traylor AM. Am Psychol. 2021;76:1-13.
The COVID-19 pandemic has dramatically affected the psychological and emotional well-being of health care workers. This article summarizes the COVID-19-related psychological effects on healthcare workers and the detrimental impact on team effectiveness. The authors recommended actions to mitigate the effects of stress on team performance and patient outcomes and discuss how teams can recover and learn from the current crisis to prepare for future challenges.
Gavin N, Romney M-LS, Lema PC, et al. BMJ Leader. 2021;5:39-41.
Developed in the field of aviation, crew resource management (CRM) is used to teach teamwork and effective communication and has been used extensively in patient safety improvement efforts. This commentary describes four New York metropolitan area emergency departments’ experience applying (CRM) principles at an organizational level in responding to the current COVID-19 pandemic as well as future crises.
Sasangohar F, Moats J, Mehta R, et al. Hum Factors. 2020;62:1061-1068.
This article discusses the role of human factors and ergonomics in disaster management and mitigating challenges associated with the COVID-19 pandemic. Key points highlighted include the use of systems approaches, improving system-wide communication and coordination, reconceptualizing expertise development, implementing agile training methods, mitigating occupational hazards, and improving procedures for disaster management tasks.
Borshoff DC, Sadleir P. Curr Opin Anaesthesiol. 2020;33:554-560.
The COVID-19 pandemic has resulted in the delivery of anesthesia outside of operating rooms, such as in emergency departments, intensive care units, and makeshift field hospitals. This review examines challenges in maintaining patient safety while providing anesthesia services in nontraditional operating room environments.  
Patient Safety Primer July 30, 2020
This primer describes stressors relevant to the healthcare response to the COVID-19 pandemic from the perspective of care deliverers and the significant personal toll the pandemic is taking on individuals who work in the healthcare system. This primer highlights foundational patient safety strategies – signage, workflow review and redesign, checklists and simulations – whose implementation is more important than ever for keeping patients and healthcare providers safe in the age of COVID-19.