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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 - 11 of 11 Results
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.
Olsen SL, Søreide E, Hansen BS. J Patient Saf. 2022;18:717-721.
Rapid response systems (RRS) are widely used to identify signs of rapid deterioration among hospitalized patients.  Using in situ simulation, researchers identified obstacles to effective RRS execution, including inconsistent education and documentation, lack of interpersonal trust, and low psychological safety.
Curated Libraries
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, care standardization,teamwork, unit-based safety initiatives, and...
Lewandowska K, Weisbrot M, Cieloszyk A, et al. Int J Environ Res Public Health. 2020;17:8409.
Alarm fatigue, which can lead to desensitization and threaten patient safety, is particularly concerning in intensive care settings. This systematic review concluded that alarm fatigue may have serious consequences for both patients and nursing staff. Included studies reported that nurses considered alarms to be burdensome, too frequent, interfering with patient care, and resulted in distrust in the alarm system. These findings point to the need for a strategy for alarm management and measuring alarm fatigue.  
Avesar M, Erez A, Essakow J, et al. Diagnosis (Berl). 2021;8:358-367.
Disruptive and rude behavior can hinder teamwork and diminish patient safety. This randomized, simulation-based study including attendings, fellows, and residents explored whether rudeness during handoff affects the likelihood for challenging a diagnostic error. The authors found that rudeness may disproportionally hinder diagnostic performance among less experienced physicians.
Hagelsteen K, Johansson B-M, Bergenfelz A, et al. J Surg Educ. 2019;76:684-693.
This educational study used a survey followed by semi-structured individual interviews with experienced surgeons to examine behaviors early in training that constitute a risk for future unprofessional behavior, a known safety concern. Researchers found that respondents consistently believed that such warning signs could be identified early in training. The authors constructed an interview guide for surgical residency admission to surface behavioral concerns.
Khamali RE, Mouaci A, Valera S, et al. JAMA. 2018;320:1988-1997.
High nurse workload has been linked to worse patient outcomes and increased burnout. In this multicenter, randomized trial involving nurses from eight intensive care units in France, researchers exposed the intervention group to a course that included simulated clinical scenarios and debriefing exercises. The simulated scenarios covered both clinical knowledge topics as well as teamwork training principles. At 6 months, they found that reported job strain was less prevalent in the intervention group. Although the study did not directly measure burnout, the results demonstrate that well-designed, targeted interventions can address factors known to result in psychological harm in the work environment.
Thompson C, Naumann DN, Fellows JL, et al. Surgeon. 2017;15:123-130.
Physicians who experience adverse effects after being involved in medical errors have been dubbed second victims. This survey of surgical trainees found that many experience psychological consequences as severe as post-traumatic stress disorder following death or serious injury to patients. Few of the participants sought mental health care, suggesting an unmet need for mental health services for trainee surgeons.
Wild JRL, Ferguson HJM, McDermott FD, et al. Int J Surg. 2015;23 Suppl 1:S5-9.
Disrespectful behaviors in health care have been found to have serious effects on nurses, physicians, and trainees. This review explores how experiences with bullying and undermining affect surgical trainees in the National Health Service and outlines recommendations to address the issue at national, organizational, and local levels.
Gallagher AG, Boyle E, Toner P, et al. Arch Surg. 2011;146:419-26.
Unprofessional behavior by clinicians poses definite patient safety threats, but most research in this area has focused on identifying and addressing disruptive behavior in the work environment. This randomized study raises the concern that physician behaviors outside of work can impair work performance. Significant worsening of simulated surgical performance was found when subjects (students and attending physicians) drank alcohol until intoxication the night before performing procedures. The authors of this study recommend that consideration be given to establishing formal recommendations for alcohol consumption prior to operating room duties. Lack of sleep prior to performing surgery has also been associated with surgical complications, and in fact, intoxication and sleep deprivation have been shown to have similar detrimental effects on physicians' cognitive performance.