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 271 Results

When mistakes multiply: how inadequate responses to medical mishaps erode trust in American medicine.

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Schlesinger M, Grob R. Hastings Cent Rep. 2023;53:s22-s32.

Involvement in patient safety incidents can erode patient trust in their own physicians and the healthcare system. This article summarizes the estimated frequency of lost trust after patient safety incidents, external factors contributing to mistrust, and approaches to restoring trust after incidents.

Public opinion of resident physician work hours in 2022.

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Weaver MD, Barger LK, Sullivan JP, et al. Sleep Health. 2023;Epub Nov 6.

Current Accreditation Council for Graduate Medical Education (ACGME) duty hour regulations limit resident work hours (no more than 80 hours per week or 24-28 consecutive hours on duty) in an effort to improve both resident and patient safety. This nationally representative survey found that over 90% of US adults disagree with the current duty hour policies, with 66% of respondents supporting additional limits on duty hours (to no more than 40 hours per week or 12 consecutive hours).

Impact Wellbeing.

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National Institute for Occupational Safety and Health. Centers for Disease Control and Prevention.

Clinician burnout has become a major concern for both healthcare workforce and patient safety. This portal provides access to tools to support organizational efforts to address the latent factors contributing to burnout such as well-being assessments and mental health access for clinicians improvement strategies.

It depends who you ask: divergences in staff and external stakeholder narratives about the causes of a healthcare failure.

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Hald EJ, Gillespie A, Reader TW. J Contingencies Crisis Manage. 2023;31:752-766.

Including both patient/relative and staff perspectives in investigations provides a deeper understanding of the event. This study applies natural language processing methodology to 40 staff and 53 patient/relative witness statements into a C. difficile outbreak in a UK trust. This novel method revealed that staff identified a lack of training and understaffing, whereas patients/relatives identified communication failures and the physical environment as contributing factors.

Psychological safety as a new ACGME requirement: a comprehensive all-in-one guide to radiology residency programs.

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Mohamed I, Hom GL, Jiang S, et al. Acad Radiol. 2023;Epub Sep 22.

Psychological safety is an important principle in identifying problems and improving patient outcomes. This narrative review highlights five best practices to foster psychological safety in radiology residencies – (1) establish clear goals and educational strategies, (2) build a formal mentoring program, (3) assess psychological safety, (4) advocate for radiologists as educators, and (5) support non-radiology staff. Although the review focuses on radiology residency programs, these strategies can be adapted to any residency program.

Middle manager responses to hospital co-workers' unprofessional behaviours within the context of a professional accountability culture change program: a qualitative analysis.

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Bagot KL, McInnes E, Mannion R, et al. BMC Health Serv Res. 2023;23:1012.

Unprofessional behavior can have a detrimental effect on coworkers, culture, and patient safety. This qualitative study presents perspectives of middle managers in hospitals that implemented a program allowing and encouraging workers to report unprofessional, as well as positive, behavior. Themes included staying silent but active (e.g., avoiding the unprofessional colleague), history and hierarchy, and double-edged swords (e.g., pros and cons of anonymous reporting).

Fragmented: A Doctor's Quest to Piece Together American Health Care.

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Yurkiewicz I. New York, NY: WW Norton & Company, Inc; 2023. ISBN: 9780393881196.

Disjointed health care processes contribute to missed test results, incomplete communication, and care omissions that harm patients. This book shares a personal account of how broken care processes serve as a core deterrent in one clinician’s ability to provide the safest care possible.

When work harms: how better understanding of avoidable employee harm can improve employee safety, patient safety and healthcare quality.

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Jones A, Neal A, Bailey S, et al. BMJ Lead. 2023;Epub Sep 10.

The well-being of healthcare workers is essential to the delivery of high quality, safe care. This article proposes a definition of “avoidable employee harm” (e.g., retaliation for speaking up about safety concerns) and describes how prioritizing organizational safety culture can increase both employee and patient safety.

How different countries respond to adverse events whilst patients' rights are protected.

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Gil-Hernández E, Carrillo I, Tumelty M-E, et al. Med Sci Law. 2023;Epub Jun 27.

Patient safety is a global health concern. For this study, representatives from 27 countries reported on rules, laws, and policies in their country related to adverse events and medical errors. As expected, laws varied widely between countries regarding issues such as apology laws, patient compensation schemes, and legal and emotional support for clinicians involved in adverse events.

California pharmacies are making millions of mistakes. They’re fighting to keep that secret.

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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.

How Columbia ignored women, undermined prosecutors and protected a predator for more than 20 years.

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Fortis B, Bell L. Pro Publica. September 12, 2023.

Sexual abuse of a patient is a never event. This article discusses how criminal behavior remained latent at a large health system due to persistent disregard of patient concerns, which enabled a serial sexual abuser to continue to practice medicine. The harm to the victims and fear of the peers who knew of the situation and were not psychologically safe enough to report it, are discussed.

Harm Caused by Delays in Transferring Patients to the Right Place of Care.

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

Handoffs between prehospital emergency medical services (EMS) providers and hospital emergency departments (EDs) can be suboptimal, which increases patient harm potential. This report examines National Health Service discharge delays. It suggests a systemic approach is needed to address flow and capacity factors that contribute to ineffective and unsafe interfacility discharge and transfer.

ICN Position Statement: Patient Safety.

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Geneva, Switzerland; International Council of Nurses: 2023.

Nursing is foundational to safe patient care. This statement outlines recommendations for the nursing community to support the World Health Organization Global Patient Safety Action Plan 2021-2030. Tactics described target, governmental, organizational, and individual actions for improvement.

Hiding in plain sight: inconvenient facts for patient safety in non-24/7 theatre on-site staffed obstetric units.

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McGurgan P. Aust N Z J Obstet Gynaecol. 2023;63:606-611.

Individual-, team-, and systems-based factors can affect safety during childbirth. This article discusses several patient safety threats that can hinder the safety of vaginal birth after cesarean (VAC) deliveries in high population density areas, including staffing and resource limitations, cultural and human factors, and patient communication.

Only 1 in 5 people with opioid addiction get the medications to treat it, study finds.

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Mann B. Health Shots. National Public Radio. August 7, 2023.

Stigma against behavioral health conditions is known to affect the quality of care relationships and therapeutic actions. This news article discusses the limited use of methadone and other medications as strategies to assist in the care and recovery of opioid use disorder patients.

Amid lack of accountability for bias in maternity care, a California family seeks justice.

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Kwon S. KFF Health News. August 8, 2023

Implicit bias and systemic racism are known to affect the safety of Black maternal care. This story describes an incident of maternal death and the family’s effort to demonstrate the role of discrimination in the outcome and hold the clinicians and organization involved responsible.

Supporting carers to improve patient safety and maintain their well-being in transitions from mental health hospitals to the community: a prioritisation nominal group technique.

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McMullen S, Panagioti M, Planner C, et al. Health Expect. 2023;26:2064-2074.

Caregivers and family members offer a unique perspective on patient safety. In this study, patient and caregiver stakeholders outlined the safety threats affecting patients discharged from mental health services and the well-being of caregivers as well as potential solutions. Participants highlighted approaches to improve caregiver involvement, patient and caregiver wellness and education, and the policy and system environments.

The Retrievals.

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Burton S. New York Times and Serial Productions. June 30-July 27, 2023.

Unnoticed drug diversion can result in harm to patients, clinicians, and organizations. This series describes how diversion contributed to unnecessary pain in fertility clinic patients. The problem was compounded by a lack of attention to women voicing their concerns about procedural pain.

Denied abortion for a doomed pregnancy, she tells Texas court: 'There was no mercy'.

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Simmons-Duffin S. Health Shots. National Public Radio. July 20, 2023.

The range of unintended consequences stemming from abortion restrictions are beginning to be documented. This news story highlights three incidents of physical and psychological patient harm resulting from lack of access to needed care during pregnancy.

Patient, carer and family experiences of seeking redress and reconciliation following a life-changing event: systematic review of qualitative evidence.

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Shaw L, Lawal HM, Briscoe S, et al. Health Expect. 2023;Epub Jul 14.

Patients who experience life-changing adverse events due to errors, and their families, typically want disclosure of the error and appropriate accountability. This systematic review identified 41 studies exploring the views of those affected by adverse events. Four themes were identified: transparency, person-centeredness, trustworthiness, and restorative justice. Applying these themes to investigations may result in ensuring the process and outcomes are experienced as "fair" to those impacted.

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