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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 34 Results
Gilbert GL, Kerridge I. BMC Health Serv Res. 2022;22:504.
Hospital transmission of COVID-19 has necessitated review of organization infection prevention and control (IPC) policies and practices. This study, conducted before the pandemic, compared IPC attitudes and practices of nurses and physicians, and how these differences affect interpersonal relationships. Both professions described unflattering and stereotypical behaviors of the other (i.e., doctors are unaware or disdainful of IPC; “bossy” nurses).  Many IPC policies implemented during the pandemic, such as encouraging all healthcare workers to speak up about infection prevention breaches, were accepted by both professions, and the authors recommend seizing on this interprofessional unity to continue adherence to all IPC policies.
Petrone G, Brown L, Binder W, et al. Disaster Med Public Health Prep. 2022;16:1780-1784.
As COVID-19 infections surged worldwide, many states set up alternative care hospitals (ACH), or field hospitals. Prior to opening a Rhode Island ACH, four multi-disciplinary in situ simulation scenarios were run to perform system testing. This in situ simulation was successful in identifying patient safety concerns, resulting in equipment modification and protocol changes.
Sands K, Blanchard J, Grubbs K, et al. Jt Comm J Qual Patient Saf. 2021;47:327-332.
This article describes the development of the Universal Protection Framework, which builds upon traditional infection prevention practices and consists of four domains (infection prevention, access control, distancing, and patient flow) supported by communication and education. The framework was implemented in one large health system with high levels of compliance, particularly for handling of personal protective equipment (PPE), cohorting of COVID-19 patients, facility access controls and employee exposure monitoring.
Pan D, Rajwani K. Simul Healthc. 2020;16:46-51.
Simulation training is employed by hospitals to improve patient care. This article describes one hospital’s experience implementing simulation training during the COVID-19 pandemic to help refine protocols, facilitate practice changes, uncover safety gaps, and train redeployed healthcare workers.

AHA Team Training.

The COVID-19 crisis requires cooperation and coordination of organizations and providers to address the persistent challenges presented by the pandemic. This on-demand video collection reinforces core TeamSTEPPS; methods that enhance clinician teamwork and communication skills to manage care safety during times of crisis. 

La Regina M, Tanzini M, Venneri F, et al for the Italian Network for Health Safety. Dublin, Ireland: International Society for Quality in Health Care; 2021.

The COVID-19 pandemic is a rapidly evolving situation that requires a system orientation to diagnosis, management and post-acute care to keep clinicians, patients, families and communities safe. This set of recommendations is anchored on a human factors approach to provide overarching direction to design systems and approaches to respond to the virus. The recommendations focus on team communication and organizational culture; the diagnostic process; patient and family engagement to reduce spread; hospital, pediatric, and maternity processes and treatments; triage decision ethics; discharge communications; home isolation; psychological safety of staff and patients, and; outcome measures. An appendix covers drug interactions and adverse effects for medications used to treat this patient population. The freely-available full text document will be updated appropriately as Italy continues to respond, learn and amend its approach during the outbreak.
Rovers JJE, van de Linde LS, Kenters N, et al. Antimicrob Resist Infect Control. 2020;9:190.
Health systems are undertaking various approaches to reduce nosocomial transmission of COVID-19. This study found that psychiatric departments may be more susceptible to hospital-acquired COVID-19 due to treating high-risk populations, lower adherence to infection prevention policies, inadequate environmental changes, and organizational policy challenges.   
Sharara-Chami R, Sabouneh R, Zeineddine R, et al. Simul Healthc. 2020;15:303-309.
Simulation training is used by hospitals to improve patient care. This article describes the use of a preparedness assessment and training intervention featuring in situ simulations followed by debriefing to prepare staff for challenges arising due to the COVID-19 pandemic. Observations and debriefings identified several latent safety threats related to infection control, leadership, and communication.
Jiménez-Pericás F, Gea Velázquez de Castro MT, Pastor-Valero M, et al. BMJ Open. 2020;10:e035238.
Isolation for infection prevention and control, albeit necessary, may result in unintended consequences for patients (e.g., less attention, suboptimal documentation and communication, higher risk of preventable adverse events [AEs]). This prospective cohort study found that the incidence of all AEs and preventable AEs were significantly higher in isolated patients compared to non-isolated patients, primarily caused by healthcare-associated infections. These findings highlight the importance of training and safety culture when providing care to patients in isolation, particularly given the expanded use of isolation due to the COVID-19 pandemic.
Levy N, Zucco L, Ehrlichman RJ, et al. Anesthesiology. 2020;133:985-996.
This article describes the experience of one hospital in eastern Massachusetts implementing rapid response capabilities in an innovative, hybrid acute care-intensive care unit. Health system leadership used failure modes and effect analysis, process mapping, and on-site walkthroughs to identify potential hazards and opportunities for risk mitigation, as well as in situ simulation drills to facilitate team training.
Mazzola SM, Grous C. AORN J. 2020;112:397-405.
This article describes strategies implemented by one hospital to help ensure patient and staff member safety during the COVID-19 pandemic, including use of personal protective equipment, decontamination efforts, mass temperature screenings, universal preprocedure testing, procedure prioritization, and modified workflows, as well as mental health support for front line clinicians and staff.

Rockville, MD: Agency for Healthcare Research and Quality; September 2020.

Nursing home residents are especially vulnerable to COVID-19 due to their age, and communal living conditions, and nursing home staff are among the most at-risk essential workers. In partnership with the University of New Mexico’s ECHO Institute and the Institute for Healthcare Improvement (IHI), AHRQ has established this network to prevent infections among nursing home residents and staff. All nursing homes that are certified to participate in the Medicare and Medicaid programs will be able to participate in a 16-week training program that includes peer-to-peer, case-based learning and additional mentorship from local and national experts. The training program will include best practices for using personal protective equipment, COVID-19 testing, clinical management of asymptomatic and mild cases, and other topics. 

Ashworth S. Elemental. September 22, 2020.

The rate of autopsies – the “gold standard” of death investigation – are decreasing worldwide. This commentary highlights the lost opportunities for hospital and clinician learning from mistakes due this decline. The author ties the relevance of the loss to missed opportunities for understanding the effect of COVID-19 on the body to inform diagnostic, treatment and prevention activities.
Dubé MM, Kaba A, Cronin T, et al. Adv Simul (Lond). 2020;5:22.
This article describes the planning and implementation of a multi-site, multidisciplinary simulation program to provide critical just-in-time COVID-19 education in one Canadian province. The authors discuss the unique features and advantages of a centralized simulation response and key themes of the simulation program.
Dharamsi A, Hayman K, Yi S, et al. J Hosp Infect. 2020;105:604-607.
This article describes the use of a rapid-cycle in-situ simulation (ISS) program to facilitate identification and resolution of organizational and systems-level safety threats (i.e., latent safety threats) involving a possible COVID-19 case. Identified threats fell in four domains: personnel, personal protective equipment, supply/environment, and communication. Most participants felt better prepared to provide care after the ISS training.
Musunur S, Waineo E, Walton E, et al. Acad Psychiatry. 2020;44:586-591.
This article describes the impact of an interactive session with second-year medical students utilizing case-based learning, small group discussion, and video vignettes intended to prepare healthcare providers to anticipate and understand the impact of medical errors. Pre- and post-surveys found that this one-hour, small-group session increased medical students’ understanding of the impact of medical errors and adverse events and the resources available to support providers.
Ingrassia PL, Capogna G, Diaz-Navarro C, et al. Adv Simul (Lond). 2020;5:13.
The authors of this article outline ten recommendations for safely reopening simulation facilities for clinical training in the post-lockdown phase of the COVID-19 crisis. The recommendations are based on national guidance and regulations, as well as international public health recommendations. Future reopening activities should focus on safety as well as flexibility principles, taking different contexts and facility characteristics into account.
Sasangohar F, Moats J, Mehta R, et al. Hum Factors. 2020;62:1061-1068.
This article discusses the role of human factors and ergonomics in disaster management and mitigating challenges associated with the COVID-19 pandemic. Key points highlighted include the use of systems approaches, improving system-wide communication and coordination, reconceptualizing expertise development, implementing agile training methods, mitigating occupational hazards, and improving procedures for disaster management tasks.
Natale JAE, Boehmer J, Blumberg DA, et al. J Interprof Care. 2020;34:682-686.
This article describes COVID-19-related surge planning in an academic medical center encompassing a children’s hospital. The article describes interdisciplinary and interprofessional teamwork to identify innovative approaches to COVID-19 response, and highlights the importance of leadership, broad inclusion, transparent decision-making and continuous communication.