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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 2066 Results
Temkin-Greener H, Mao Y, McGarry B, et al. J Am Med Dir Assoc. 2022;Epub Oct 18.
Long-term care facilities can struggle with establishing a safety culture. Researchers in this study used a national survey on nursing home safety culture to assess patient safety culture in assisted living facilities. Findings show that direct care workers had significantly worse perceptions of patient safety culture (including nonpunitive responses to mistakes, management support for resident safety, and teamwork) compared to administrators. A PSNet perspective discusses how to change safety culture.
Gogalniceanu P, Karydis N, Costan V-V, et al. J Am Coll Surg. 2022;235:612-623.
Safety strategies from high-reliability industries such as aviation and nuclear power are frequently adapted for healthcare. In this study, pilots described crisis preparedness strategies, which surgical safety experts then developed into a framework consisting of six behavioral interventions: anticipate threats, briefing, checklists, drill rehearsal, individual and team empowerment, and debriefing. An earlier study by the authors describes the second phase in managing crisis: crisis recovery.
Derdowski LA, Mathisen GE. Safety Sci. 2022;157:105948.
Work-related psychosocial factors may increase or decrease the risk of accidents in high-risk industries (e.g., nuclear, mining, healthcare). Using the Job Demands-Resources (JD-R) framework as a starting point, associations between job demands and resources, and between safety behaviors and outcomes were evaluated. Most studies report on the link between psychosocial factors and safety behavior (e.g., job stress or exhaustion can precede negative safety behavior).
M. Violato E. Can J Respir Ther. 2022;58:137-142.
Healthcare trainees and junior clinicians are often reluctant to speak up about safety concerns. This qualitative study found that simulation training to enhance speaking up behaviors had lasting effects among advanced care paramedics and respiratory therapists as they moved from training into practice. Respondents highlighted the importance of experience for speaking up and the benefits of high-impact simulation training.
Wilson M-A, Sinno M, Hacker Teper M, et al. J Patient Saf. 2022;18:680-685.
Achieving zero preventable harm is an ongoing goal for health systems. In this study, researchers developed a five-part strategy to achieve high-reliability and eliminate preventable harm at one regional health system in Canada – (1) engage leadership, (2) develop an organization-specific patient safety framework, (3) monitor specific quality aims (e.g., high-risk, high-cost areas), (4) standardize the incident review process, including the use of root cause analysis, and (5) communicate progress to staff in real-time via electronic dashboards. One-year post-implementation, researchers observed an increase in patient safety incident reporting and improvements in safety culture, as well as decreases in adverse events such as falls, pressure injuries and healthcare-acquired infections.
Silva B, Ožvačić Adžić Z, Vanden Bussche P, et al. Int J Environ Res Public Health. 2022;19:10515.
The COVID-19 pandemic led to dramatic changes in healthcare delivery. The multi-country PRICOV-19 study evaluated how primary care practices reorganized their day-to-day work during the pandemic and the impacts on patient safety culture. This study compared training vs. non-training primary care practices and found that training practices had a stronger safety culture during the pandemic.

Hare R, Tapia A, Tyler ER, Fan L, et al. Rockville, MD: Agency for Healthcare Research and Quality; October 2022. AHRQ Publication No. 22(23)-0066.

Instituting a culture of safety is fundamental to ensuring patient and staff safety. The AHRQ Hospital Survey on Patient Safety Culture (SOPS®) is a validated survey that has been widely used to assess patient safety culture since 2004. The 2022 report includes data from 400 hospitals. The highest “percent positive” composite measure scores included both effective teamwork and supervisor, manager, or clinical leader support for suggestions for improving patient safety, and addressing patient safety concerns. Overall, when asked to rate their unit/work area on patient safety, 67 percent of respondents rated their unit/work area as “Excellent” or “Very Good.”
Cartland J, Green M, Kamm D, et al. BMJ Open Qual. 2022;11:e001757.
Psychological safety is a cornerstone of high reliability organizations (HROs). This children’s hospital developed two scales (trust in team members and trust in leadership) and one composite measure (local learning) to measure staff psychological safety and evaluate the effectiveness of their transition to high reliability. More than 4,500 health system staff completed the survey; results indicate the two scales are strongly associated with the composite measure.
McCain N, Ferguson T, Barry Hultquist T, et al. J Nurs Care Qual. 2022;Epub Aug 19.
Daily huddles can improve team communication and awareness of safety incidents. This single-site study found that implementation of daily interdisciplinary huddles increased reporting of near-miss events and improved team satisfaction and perceived team communication, collaboration, and psychological safety.

Chicago, IL: The National Association for Healthcare Quality; 2022.

Quality and safety work requires distinct competencies to support effective action and systemic approaches to improvement. This report highlights areas of emphasis and weakness across quality domains and the need for health organization leadership to train and direct designated staff to realize quality and safety goals.
Harton L, Skemp L. J Nurs Manag. 2022;Epub Sep 1.
Nurse leaders play an important role in ensuring a robust patient safety culture. Ten nurse leaders at a United States hospital provided their perspectives on how they ensure a culture of safety on their units. Six overarching themes emerged as well as structural and organizational challenges.
Cakir MS, Wardman JK, Trautrims A. Risk Anal. 2022;Epub Oct 19.
Transparency, communication, and value alignment between staff and leaders increase staff trust and comfort in speaking up about concerns. This study describes the relationship of employees’ perception of ethical leadership (manager sets an example of ethical behavior), safety voice (comfort speaking up about COVID-19), ethical ambiguity regarding work responsibilities, and risk perception of coronavirus. Employees who rated their leaders as behaving more ethically were more comfortable speaking up about COVID-19 concerns.
Lauffenburger JC, Coll MD, Kim E, et al. Med Educ. 2022;56:1032-1041.
Medication errors can be common among medical trainees. Using semi-structured qualitative interviews, this study identified factors influencing suboptimal prescribing by medical residents during overnight coverage, including time pressures, perceived pressure and fear of judgement, clinical acuity, and communication issues between care team members.
Rockville, MD: Agency for Healthcare Research and Quality.
In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. The 2022 report discusses a decrease in life expectancy due to the COVID-19 pandemic. It also reviews the current status of special areas of interest such as maternity care, child and adolescent mental health, and substance abuse disorders. 
Charles MA, Yackel EE, Mills PD, et al. J Patient Saf. 2022;18:686-691.
The first surge of the COVID-19 pandemic forced healthcare organizations to respond to patient safety issues in real-time. The Veterans Health Administration’s National Center for Patient Safety established two working groups to rapidly monitor quality and safety issues and make timely recommendations to staff. The formation, activities, and primary themes of safety issues are described.
Ellis LA, Pomare C, Churruca K, et al. BMJ Open. 2022;12:e065320.
A strong safety culture encourages error reporting and supports a blame-free environment, and is frequently measured to develop appropriate interventions. This review identified nearly 900 studies that assessed hospital safety culture with response rates from 4% to 100%. The authors identify several factors that influence response rate: remote distribution (i.e., electronic or sent via mail), timing (e.g., beginning/end of resident rotations, COVID-19), and length of survey.
Pappa D, Koutelekos I, Evangelou E, et al. Healthcare (Basel). 2022;10:1803.
The physical and psychological well-being of healthcare providers can also improve patient safety. A survey of 364 nurses found that somatic symptoms (e.g., headache, exhaustion, fatigue) had a positive correlation with nursing errors, but other symptoms of burnout – such as anxiety or depression – did not. Resilience was associated with all aspects of general health and can be a helpful coping mechanism to prevent harm.

Dixon-Woods M, Martin G, eds. Cambridge, UK: Cambridge University Press; 2022.

Improvement activities are complex initiatives that require synergistic actions by organizations to be sustained. This evolving series provides background, evidence, and discussion on interdisciplinary strategies known to affect quality and safety such as implementation science, collaboration, positive deviance, and culture change.

Cooper J, Thomas BJ, Rebello E, et al for the APSF Criminalization of Error Task Force. APSF Newsletter. October 2022; 37(3):80-81

Criminalizing human error can deter the transparency necessary to learn from incidents and improve health care. This position statement articulates the importance of avoiding the criminal prosecution to mistakes to instead focus on system failures to prevent conditions that permit errors to harm patients.
Institute for Safe Medication Practices. December 1-2, 2022.
This virtual workshop will explore tactics to ensure medication safety, including strategic planning, risk assessment, and Just Culture principles.