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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 20 Results
May 4, 2023
The implementation of effective patient safety initiatives is challenging due to the complexity of the health care environment. This curated library shares resources summarizing overarching ideas and strategies that can aid in successful program execution, establishment, and sustainability.
Curated Libraries
March 8, 2023
Value as an element of patient safety is emerging as an approach to prioritize and evaluate improvement actions. This library highlights resources that explore the business case for cost effective, efficient and impactful efforts to reduce medical errors.
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.

Cox C, Fritz Z. BMJ. 2022;377:e066720.

As more patients are gaining access to their electronic health records, including clinician notes, the language clinicians use can shape how patients feel about their health and healthcare provider. This commentary describes how some words and phrases routinely used in provider notes, such as “deny” or “non-compliant”, may inadvertently build distrust with the patient. The authors recommend medical students and providers reconsider their language to establish more trusting relationships with their patients.
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, collaborative initiatives, teamwork, and trigger tools.

Farnborough, UK: Healthcare Safety Investigation Branch; June 2021.

Wrong site/wrong patent surgery is a persistent healthcare never event. This report examines National Health Service (NHS) reporting data to identify how ambulatory patient identification errors contribute to wrong patient care. The authors recommend that the NHS use human factors methods to design control processes to target and manage the risks in the outpatient environment such as lack of technology integration, shared waiting area space, and reliance on verbal communication at clinic.
Debesay J, Kartzow AH, Fougner M. Nurs Inq. 2021;29:e12421.
Previous studies have shown that ethnic minority patients are at an increased risk of adverse events. Using critical incidents and provider reflections, this study highlights the challenges faced by healthcare providers when providing care for ethnic minority patients. Similar reflection processes in the work environment may contribute to better coping strategies and improved relationships with ethnic minority patients. 
Kozasa EH, Lacerda SS, Polissici MA, et al. Front Psych. 2020;11:570786.
Situational awareness during critical incidents is a key component of teamwork. This study found that a mutual care training can increase situational awareness for healthcare workers and consequently improve mental health and well-being before and during the COVID-19 pandemic.
Graham C, Reid S, Lord TC, et al. Br Dent J. 2019;226:32-38.
Reporting and avoidance of “never events,” such as a wrong tooth extraction, is important for providing consistently safe dental care. This article describes changes made in safety procedures, including introducing surgical safety briefings or huddles in an outpatient oral surgery unit of the United Kingdom’s National Health Service, that eliminated never events for more than two years.
Schwappach DLB, Niederhauser A.  Int J Ment Health Nurs. 2019;28:1363-1373.
This study focused on healthcare workers speaking-up behavior in six psychiatric hospitals in Switzerland. The authors found significant differences in speaking-up despite having moderate to high scores on items that were associated with psychological safety. Although nurses reported patient safety concerns more frequently, they also remained silent more often compared with psychologists and physicians, indicating they may feel less psychological safety.
BMJ. 2018;363:k3033.
Patients who experience care complications are vulnerable to psychological consequences that can affect their relationship with their clinical teams. This commentary relates insights from a patient who experienced complications resulting from care, the negative impact on her relationship with her surgeon, and how she felt when her surgeon expressed empathy. The author offers recommendations for clinicians to demonstrate their concern and improve practice when problems occur.
Phadnis J, Templeton-Ward O. J Patient Saf. 2018;14:82-86.
Though preoperative briefings are recommended to enhance team communication, they are incompletely implemented and evidence regarding their benefit is not well-established. This audit study found that inadequate preoperative briefings resulted in more minor adverse events. This finding adds to the evidence of their importance but does not address implementation challenges.
Harrison R, Lawton R, Stewart K. Clin Med (Lond). 2014;14:585-90.
According to this survey study, physicians involved in adverse events experience personal and professional harm, and existing reporting practices are not helpful. These findings suggest that despite prior work, systems to address physician needs remain inadequate. Dr. Albert Wu discussed the second victim phenomenon in a past AHRQ WebM&M interview.
Abd Elwahab S, Doherty E. The Surgeon. 2014;12.
Medical errors affect not only the patients and families involved, but the clinicians and organization as well. This commentary focuses on physicians as second victims and how mistakes influence their emotional health, stress levels, and work performance.
Corbally MT, Tierney E. Int J Pediatr. 2014;2014:791490.
Many institutions are attempting to increase patient and family engagement in safety efforts. This report on integrating parents of children undergoing surgery into the completion of the WHO surgical safety checklist provides a helpful example of families being successfully incorporated into an existing safety program.
London, England: NHS Resolution; 2018.
Although victims of adverse events have clearly expressed their preferences for full error disclosure, most physicians remain uncomfortable with disclosing and apologizing for errors. This leaflet offers information to help clinicians understand the value of effective apologies along with tips for organizations to support open disclosure efforts.