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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 1357 Results
WebM&M Case November 29, 2023

This case describes a 55-year-old woman who sustained critical injuries after a motor vehicle crash and had a lengthy hospitalization. On hospital day 30, a surgeon placed a percutaneous endoscopic gastrostomy (PEG) tube in the intensive care unit (ICU) after computed tomography (CT) scan showed no interposed bowel between the stomach and the anterior abdominal wall.  After the uncomplicated PEG placement, the surgeon cleared the patient’s team to advance tube feeds as tolerated.

Cam H, Wennlöf B, Gillespie U, et al. BMC Health Serv Res. 2023;23:1211.
When patients are discharged from the hospital, they (and their informal caregivers) are given copious amounts of information that must also be communicated to their primary care provider. This qualitative study of primary care and hospital physicians, nurses, and pharmacists highlights several barriers to complete and effective communication between levels of care, particularly regarding geriatric medication safety. Barriers include the large number of complex patients and incongruent expectations of responsibility of primary and hospital providers. Support systems, such as electronic health records, can both enable and hinder communication.
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).

Washington DC; VA Office of the Inspector General; October 31, 2023; Report no. 22-03599-07.

Disclosure failures detract from learning, appropriate incident examination, and safe care delivery. This report examined factors contributing to poor disclosure practices associated with the care of three patients. Lack of report submission, uninitiated root cause analysis, and inadequate documentation were process weaknesses highlighted by the review. 
Olazo K, Gallagher TH, Sarkar U. J Patient Saf. 2023;19:547-552.
Marginalized patients are more likely to experience adverse events and it is important to encourage effective disclosure to reinforce and reestablish trust between patients and providers. This qualitative study involving clinicians and patient safety professionals explored challenges responding to and disclosing errors involving historically marginalized patients. Participants identified multilevel challenges, including fragmentation of care and patient mistrust as well a desire for disclosure training and culturally appropriate disclosure toolkits to support effective error disclosure.
Gallois JB, Zagory JA, Barkemeyer B, et al. Pediatr Qual Saf. 2023;8:e695.
Structured handoff tools can improve situational awareness and patient safety. This study describes the development and implementation of a bespoke tool for handoffs from the operating room to the neonatal intensive care unit (NICU). While use remained inconsistent during the study period, the goal of 80% compliance was achieved and 83% surveyed staff agreed or strongly agreed that the handoff provided needed information, up from 21% before implementation.

Rickert J, Järvinen TLN, Lee MJ, et al. Clin Orthop Relat Res. 2013-2023.

This quarterly commentary explores a wide range of subjects associated with patient safety, such as the impact of disruptive behavior on teams, the value of apologies, and safety challenges inherent in clinician strike actions. Older materials are available online for free.
Armstrong Institute for Patient Safety and Quality.
The comprehensive unit-based safety program (CUSP) approach emphasizes improving safety culture through a continuous process of reporting and learning from errors, improving teamwork, and engaging staff at all levels in safety efforts. Available on demand and live, this session covers how to utilize CUSP, including understanding and addressing challenges to implementation. The next virtual session will be held January 16, 2024.
Ramjaun A, Hammond Mobilio M, Wright N, et al. Ann Surg. 2023;278:e1142-e1147.
Situational awareness is an essential component of teamwork. This qualitative study examined how situational awareness and team culture impact intraoperative handoff practice. Researchers found that participants often assumed that team members are interchangeable and that trained staff should be able to determine handoff appropriateness without having to consult the larger operating room team – both of these assumptions hinder team communication and situational awareness.
van Moll C, Egberts TCG, Wagner C, et al. J Patient Saf. 2023;19:573-579.
Diagnostic testing errors can contribute to delays in diagnosis and to serious patient harm. Researchers analyzed 327 voluntary incident reports from one medical center in the Netherlands and found that diagnostic testing errors most commonly occurred during the pre-analytic phase (77%), and were predominantly caused by human factors (59%). The researchers found that these diagnostic testing errors contributed to a potential diagnostic error in 60% of cases.
Armstrong Institute for Patient Safety and Quality. January 30 and February 1, 2024.
Team training programs seek to improve communication and coordination among team members to reduce the potential for medical error. This virtual workshop will train participants to design, implement, and evaluate team training programs in their organizations based on the TeamSTEPPS model. 
Yung AHW, Pak CS, Watson B. Int J Qual Health Care. 2023;35:mzad065.
Cognitive aids such as mnemonics can help improve process reliability and promote patient safety. Based on an initial scoping review, this article describes a proposed taxonomy for clinical handoff mnemonics and their clinical processes and functions, which could help clinical teams design handoff mnemonics that best fit their workplace.
Huth K, Hotz A, Emara N, et al. J Patient Saf. 2023;19:493-500.
The transition from hospital to home is a vulnerable time as patients may have changes in medications or care needs, or difficulties accessing follow up with an outpatient provider. To reduce adverse events (AE), rehospitalizations, and emergency department visits, this hospital developed a structured discharge bundle based on the I-PASS tool used for inpatient handoffs. AE, rehospitalizations, and emergency department visits were all reduced following implementation of the I-PASS bundle.
Rao A, Heidemann LA, Hartley S, et al. Clin Teach. 2023;Epub Aug 26.
Accurate and complete clinical documentation is essential to high quality, safe healthcare. In this simulation study, senior medical residents responded to pages regarding sepsis or atrial fibrillation (phone encounter) and documented a brief note regarding the encounter afterwards (documentation encounter). The study found that written documentation following a clinical encounter included more important clinical information (e.g., ordering blood cultures for sepsis, placing a patient on telemetry) compared to what was discussed during the phone encounter.
Office of Health Care Quality. Baltimore, MD: Maryland Department of Health and Mental Hygiene.
This annual report summarizes never events in Maryland hospitals over the previous year. During fiscal year 2022, reported events increased due to the COVID pandemic, workforce shortages and other system demands. Events contributing to patient deaths and severe harm from preventable medical errors during the time period doubled. The authors recommend several corrective actions to enhance improvement work, including board and executive leadership engagement in safety work and application of high-reliability concepts to enhance safety culture.
Cornell EG, Harris E, McCune E, et al. Diagnosis (Berl). 2023;10:417-423.
Structured handoffs can improve the quality of patient information passed from one care team to another. This article describes intensivists' perspectives on a potential handoff tool (ICU-PAUSE) for handoff from the intensive care unit (ICU) to medical ward. They described the usefulness of a structured clinical note, especially regarding pending tests and the status of high-risk medications. Several barriers were also discussed, such as the frequent training required for residents who rotate in and out of the ICU and potential duplication of the daily chart note.
WebM&M Case September 27, 2023

A 42-year-old man with a history of posttraumatic stress disorder (PTSD), alcohol use disorder and anxiety disorder, was seen in the emergency department (ED) after a high-risk suicide attempt by hanging. The patient was agitated and attempted to escape from the ED while on an involuntary psychiatric commitment. The ED staff treated him as a “routine boarder” awaiting an inpatient bed, with insufficiently robust behavioral monitoring.

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.