The PSNet Collection

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.

Curated Libraries

Patient as a Team Member in Clinical Care

October 23, 2023

This curated library highlights concepts associated with the patient as a partner for safety at the team level directly connected to personal clinical encounters.

Improving Diagnostic Safety and Quality

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Perspective on Safety April 26, 2023

Throughout 2022, AHRQ PSNet has shared research that elucidates the complex nature of misdiagnosis and diagnostic safety. This Year in Review explores recent work in diagnostic safety and ways that greater safety may be promoted using tools developed to improve diagnostic practices.

Impact of System Failures on Healthcare Workers

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Perspective on Safety March 21, 2023

Throughout 2022, the impact of system failures on healthcare workers was a recurrent theme of articles on AHRQ PSNet. This Year in Review explores these impacts and ways to support healthcare workers involved in a system failure.

Curated Libraries

Diagnostic Safety

October 10, 2022

Selected PSNet materials for a general safety audience focusing on improvements in the diagnostic process and the strategies that support them to prevent diagnostic errors from harming patients.

Identifying Safety Events in the Prehospital Setting

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Perspective on Safety May 16, 2022

This piece focuses on measuring and monitoring patient safety in the prehospital setting.

In Conversation With... Remle P. Crowe, PhD

Remle Crowe, PhD, NREMT, is the Director of Clinical and Operational Research at ESO. In her professional role, she provides strategic direction for the research mission of the organization, including oversight of a warehouse research data set of de-identified records (the ESO Data Collaborative). We spoke with her about how data is being used in the prehospital setting to improve patient safety.

Curated Libraries

Maternal Safety

September 13, 2021

Ensuring maternal safety is a patient safety priority. This library reflects a curated selection of PSNet content focused on improving maternal safety. Included resources explore strategies with the potential to improve maternal care delivery and outcomes, such as high reliability, collaborative initiatives, teamwork, and trigger tools.

Public sector organizational failure: a study of collective denial in the UK national health service.

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Hendy J, Tucker DA. J Bus Ethics. 2020;2021;172:691–706.

Using the events at the United Kingdom’s Mid Staffordshire Trust hospital as a case study, the authors discuss the impact of ‘collective denial’ on organizational processes and safety culture. The authors suggest that safeguards allowing for self-reflection and correction be implemented early in the safety reporting process, and that employees be granted power to speak up about safety concerns.

Delayed Management of Necrotizing Soft Tissue Infection – Who does the Patient Belong To?

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WebM&M Case April 29, 2020

A 52-year old women presented to the emergency department with a necrotizing soft tissue infection (necrotizing fasciitis) after undergoing cosmetic abdominoplasty (‘tummy tuck’) elsewhere. A lack of communication and disputes between the Emergency Medicine, Emergency General Surgery and Plastic Surgery teams about what service was responsible for the patient’s care led to delays in treatment. These delays allowed the infection to progress, ultimately requiring excision of a large area of skin and soft tissue.

Patient Safety 101

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Patient Safety Primer September 7, 2019

This Primer provides an overview of the history and current status of the patient safety field and key definitions and concepts. It links to other Patient Safety Primers that discuss the concepts in more detail.

Patient safety professionals as the third victims of adverse events.

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Holden J, Card AJ. J Patient Saf Risk Manag. 2019;24:166-175.

Negative consequences can radiate throughout an organization after a patient harm event. This commentary provides an overview of first victims, second victims, and third victims of medical errors, then elaborates on how patient safety professionals responsible for investigating adverse incidents and designing improvements can experience emotional stress, bullying, and staff turnover. The authors recommend increased support and measurement of the impact of patient safety events on these individuals.

Chasing zero harm in radiation oncology: using pre-treatment peer review.

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Vijayakumar S, Duggar WN, Packianathan S, et al. Front Oncol. 2019;9:302.

Huddles are increasingly being used to improve safety in hospitals. This commentary describes how one hospital implemented structured multidisciplinary prospective peer review of radiation oncology patient treatment plans to help prevent harm and reduce errors. The authors discuss safety culture and minimizing clinical hierarchy as drivers of success.

The impact of errors on healthcare professionals in the critical care setting.

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Kaur AP, Levinson AT, Monteiro JFG, et al. J Crit Care. 2019;52:16-21.

The second victim effect has been used to describe the emotional impact that providers may experience when involved in a medical error, adverse event, or unanticipated patient outcome. In this survey study, researchers found that members of a critical care society frequently admitted to experiencing negative emotions such as blame and guilt when responding to questions involving scenarios of different types of errors. Nearly 70% of respondents suggested that team debriefings and talking with colleagues could help mitigate the second victim effect.

Second victims need emotional support after adverse events: even in a just safety culture.

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Schrøder K, Lamont RF, Jørgensen JS, et al. BJOG. 2019;126:440-442.

Medical errors can have emotional consequences for clinicians. This commentary emphasizes the importance of organizational support for second victims to ensure that these providers receive assistance from their colleagues to remain healthy and productive. The authors suggest that peer support programs are also required in organizations with blame-free cultures to support providers who feel guilt after an error.

Impact of patient safety culture on missed nursing care and adverse patient events.

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Hessels AJ, Paliwal M, Weaver SH, et al. J Nurs Care Qual. 2019;34:287-294.

This cross-sectional study examined associations between safety culture, missed nursing care, and adverse events. Investigators found significant associations between worse ratings of safety culture and more reports of missed nursing care. They recommend enhancing safety culture to reduce missed nursing care and improve safety.

Another round of the blame game: a paralyzing criminal indictment that recklessly "overrides" just culture.

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ISMP Medication Safety Alert! Acute Care Edition. February 14, 2019;24.

Reporting on the criminal indictment of a nurse involved in the death of a patient, this newsletter article reviews factors that contributed to the failure, urges leadership to modify the use of blame tactics in response to medical mistakes, and highlights guidelines to prevent similar incidents.

Spotlight: Mistaken Attribution, Diagnostic Misstep

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WebM&M Case January 1, 2019

A woman with a history of psychiatric illness presented to the emergency department with agitation, hallucinations, tachycardia, and transient hypoxia. The consulting psychiatric resident attributed the tachycardia and hypoxia to her underlying agitation and admitted her to an inpatient psychiatric facility. Over the next few days, her tachycardia persisted and continued to be attributed to her psychiatric disease. On hospital day 5, the patient was found unresponsive and febrile, with worsening tachycardia, tachypnea, and hypoxia; she had diffuse myoclonus and increased muscle tone.

Still Failing the Frail.

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Simmons-Ritchie D. Penn Live. November 15, 2018.

Nursing home patients are vulnerable to preventable harm due to poor safety culture, insufficient staffing levels, lack of regulation enforcement, and misaligned financial incentives. This news investigation reports on how poor practices resulted in resident harm in Pennsylvania nursing homes and discusses strategies for improvement, such as enhancing investigation processes.

The emotional fallout from the culture of blame and shame.

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Ferguson CC. JAMA Pediatr. 2017;171:1141.

In this commentary, a physician recounts a mistake that led to an infant patient's death, critical statements made by senior faculty members after the incident, and feeling shame that affected her work and home life. The piece discusses approaches for enabling other clinicians to manage shame associated with poor outcomes through disclosure, introspection, and compassion for the fallibility of care providers.

Second Victim: Error, Guilt, Trauma, and Resilience.

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Dekker S. Boca Raton, FL: CRC Press; 2013. ISBN: 9781466583412.

This book covers how to investigate patient safety incidents while simultaneously providing support for second victims.

Medical error: the second victim.

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McCay L, Wu AW. Br J Hosp Med (Lond). 2012;73:C146-148.

Exploring how medical errors affect second victims, this commentary recommends strategies to help them cope with such experiences.

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