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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 994 Results
Sutton E, Booth L, Ibrahim M, et al. Qual Health Res. 2022;32:2078-2089.
Patient engagement and encouragement to speak up about their care can promote patient safety. This qualitative study explored patients’ psychosocial experiences after surviving abdominal surgery complications. Findings highlight an overarching theme of vulnerability and how power imbalances between patients and healthcare professionals can influence speaking up behaviors.
Enumah SJ, Sundt TM, Chang DC. J Healthc Manag. 2022;67:367-379.
Hospitals that implement quality improvement initiatives improve patient safety but also incur financial expenses related to implementation, sustainment, and reporting. This study used data from the American Hospital Association and Hospital Compare to evaluate the relationship of financial performance and quality in hospitals performing cardiac surgery. The findings indicate hospitals with lower Patient Safety Indicator 90 (PSI 90) scores had poorer financial performance in the following year.
Carmack A, Valleru J, Randall KH, et al. Jt Comm J Qual Patient Saf. 2023;49:3-13.
Retained surgical items (RSI) are a never event, a serious and preventable event. After experiencing a high rate of RSIs, this United States health system implemented a bundle to reduce RSI, improve near-miss reporting, and increase process reliability in operating rooms. The bundle consisted of five elements: surgical stop, surgical debrief, visual counters, imaging, and reporting.
Curated Libraries
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.
Uramatsu M, Maeda H, Mishima S, et al. J Cardiothorac Surg. 2022;17:182.
Wrong-patient transfusion errors can lead to serious patient harm. This case report describes a blood transfusion error and summarizes the systems issues that emerged during the root case analysis, as well as the corrective steps implemented by the hospital to prevent future transfusion errors. A previous Spotlight Case featured a near-miss transfusion error and strategies for ensuring safe transfusion practices.

Otolaryngol Head Neck Surg. 2018-2022.

Otolaryngology-head and neck surgery is vulnerable to wrong site errors and other challenges present in surgical care. This series of articles highlights key areas of importance for the specialty as they work to enhance patient safety. The latest 2022 installment covers psychological safety.
Taylor DJ, Goodwin D. J Med Ethics. 2022;48:672-677.
Normalization of deviance describes a situation where individuals, teams or organizations accept a lower standard of performance until that lower standard becomes the “norm” and can threaten patient safety. This article describes five serious medical errors in obstetrics and highlights how normalization of deviance contributed to each event.
Marsh KM, Turrentine FE, Knight K, et al. Ann Surg. 2022;275:1067-1073.
Having standardized definitions and classifications of errors allows researchers to better understand potential causes and interventions for improvement. This systematic review identified six broad error categories, 13 definitions of error, and 14 study methods in the surgical error literature. Development and use of a common definition and taxonomy of errors will provide a more accurate indication of the prevalence of surgical error rates.
Ramsey L, McHugh SK, Simms-Ellis R, et al. J Patient Saf. 2022;18:e1203-e1210.
Patients and families can contribute unique insights into medical errors. This qualitative evidence review concluded that patients and families value involvement in patient safety incident investigations but highlight the importance of addressing the emotional aspects of care (e.g., timely apology, prioritizing trust and transparency). Healthcare staff perceived patient and family involvement in investigations to be important, but cited several barriers (e.g., staff turnover, fears of litigation) to effective investigations.
Weston M, Chiodo C. AORN J. 2022;115:569-575.
Unintentionally retained foreign objects can be exacerbated by fatigue, distractions, and communication errors. This article highlights the importance of effective teamwork, high reliability orientation, and standardized surgical count methods to minimize the persistent problem of retained surgical items.
Levkovich BJ, Orosz J, Bingham G, et al. BMJ Qual Saf. 2022;Epub Jul 5.
Rapid response teams, also known as medical emergency teams (MET), are activated when a patient demonstrates signs of clinical deterioration to prevent transfer to intensive care, cardiac arrest, and death. MET activations were prospectively reviewed at two Australian hospitals to determine the proportion of activations due to medication-related harms and assess the preventability of the activation. 23% of MET activations were medication-related, and 63% of those were considered preventable. Most preventable activations were patients with hypertension, and prevention strategies should focus on these patients.
Baartmans MC, Hooftman J, Zwaan L, et al. J Patient Saf. 2022;18:e1135-e1141.
Understanding human causes of diagnostic errors can lead to more specific targeted, specific recommendations and interventions. Using three classification instruments, researchers examined a series of serious adverse events related to diagnostic errors in the emergency department. Most of the human errors were based on intended actions and could be classified as mistakes or violations. Errors were more frequently made during the assessment and testing phases of the diagnostic process.
Morsø L, Birkeland S, Walløe S, et al. Jt Comm J Qual Patient Saf. 2022;48:271-279.
Patient complaints can provide insights into safety threats and system weaknesses. This study used the healthcare complaints analysis tool (HCAT) to identify and categorize safety problems in emergency care. Most problems arose during examination/diagnosis and frequently resulted in diagnostic errors or errors of omission.
Tan J, Krishnan S, Vacanti JC, et al. J Healthc Risk Manag. 2022;42:9-14.
Inpatient falls are a common patient safety event and can have serious consequences. This study used hospital safety reporting system data to characterize falls in perioperative settings. Falls represented 1% of all safety reports between 2014 and 2020 and most commonly involved falls from a bed or stretcher. The author suggests strategies to identify patients at high risk for falls, improve fall-related training for healthcare personnel, and optimize equipment design in perioperative areas to prevent falls.
Davidson C, Denning S, Thorp K, et al. BMJ Qual Saf. 2022;31:670-678.
People of color experience disproportionately higher rates of maternal morbidity and mortality. As part of a larger quality improvement and patient safety initiative to reduce severe maternal morbidity from hemorrhage (SMM-H), this hospital analyzed administrative data stratified by race and ethnicity, and noted a disparity between White and Black patients. Review of this data was integrated with the overall improvement bundle. Post-implementation results show that SMM-H rates for Black patients decreased.
Reijmerink IM, Bos K, Leistikow IP, et al. Br J Surg. 2022;109:573-575.
Organizational, environmental, and work-related factors can contribute to performance variations and human error during healthcare delivery. This study examined perioperative sentinel events reported to a Dutch database over a one-year period. It found that although performance variability continued in almost all events, it was rarely explicitly mentioned in incident reports or represented in resulting improvement measures. The authors suggest that explicitly addressing performance variability in sentinel event analyses can lead to more effective improvement measures that account for human performance in healthcare.