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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 230 Results

Järvinen TLN, Rickert J, 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 due to COVID-19. Older materials are available online for free.
Riman KA, Harrison JM, Sloane DM, et al. Nurs Res. 2023;72:20-29.
Operational failures – breakdowns in care processes, such as distractions or situational constraints – can impact healthcare delivery. This cross-sectional analysis using population-based survey data from 11,709 nurses examined the relationship between operational failures, patient satisfaction, nurse-reported quality and safety, and nurse job outcomes. Findings indicate that operational failures negatively impact patient satisfaction, quality and safety, and contribute to poor nurse job outcomes, such as burnout.  
Engel JR, Lindsay M, O'Brien S, et al. J Nurs Adm. 2022;52:511-518.
Alert fatigue occurs when healthcare workers become desensitized to alarms over time, especially when alarms tend to be clinically nonsignificant, and therefore, ignored or not responded to. This study reports on one health system’s redesign of cardiac monitoring structure to reduce alert fatigue. Through a four-phase quality improvement project, three hospitals were able to decrease alarms by 74-95% and sustained the results for 12 months.
Henry Basil J, Premakumar CM, Mhd Ali A, et al. Drug Saf. 2022;45:1457-1476.
Medication administration errors (MAEs) are thought to be common in neonatal intensive care units (NICUs). This systematic review estimated that the pooled prevalence of MAEs among patients in NICU settings ranged from 59% to 65%. The review highlights both active failures (e.g., similar drug packaging or names) and latent failures (e.g., noisy environments, inaccurate verbal or written orders) contributing to MAEs.
Adamson HK, Foster B, Clarke R, et al. J Patient Saf. 2022;18:e1096-e1101.
Computed tomography (CT) scans are important diagnostic tools but can present serious dangers from overexposure to radiation. Researchers reviewed 133 radiation incidents reported to one NHS trust from 2015-2018. Reported events included radiation incidents, near-miss incidents, and repeat scans. Most events were investigated using a systems approach, and staff were encouraged to report all types of incidents, including near misses, to foster a culture of safety and enable learning.

Kaplan A. NBC News. October 27, 2022. 

Suboptimal working conditions are a known contributor to errors in retail pharmacies. This news article discusses how one major pharmacy chain will adjust their staff quality metrics to eliminate timing as a performance measure in the interest of reducing pharmacist and staff burnout and fulfilment errors.
Aziz S, Barber J, Singh A, et al. J Hosp Med. 2022;17:880-887.
The introduction of new technology can have mixed consequences on staff workflows and patient safety. Focus groups of residents and nurses in a California children’s hospital sought to assess the advantages and shortcomings of secure text messaging systems (STMS) on teamwork, patient safety, and clinician well-being. Guidelines to reduce drawbacks are described.
Dzisko M, Lewandowska A, Wudarska B. Sensors (Basel). 2022;22:3536.
Interruptions and distractions in healthcare settings can inhibit safe care. This simulation study found that medical staff reaction time to changes in vital signs during stressful situations (telephone ringing, ambulance signal) was significantly slower than during non-stressful situations, which may increase the likelihood of medical errors.
Alexander R, Waite S, Bruno MA, et al. Radiology. 2022:212631.
To reduce medical errors caused by fatigue, the Accreditation Council for Graduate Medical Education (ACGME) adopted duty hour restrictions for ACGME-accredited residency programs; however, other healthcare fields have not yet done so. This review presents the limited existing evidence for regulating duty hours for radiologists and proposes that additional research needs to be completed before implementing restrictions.
Hunter J, Porter M, Cody P, et al. Int Emerg Nurs. 2022;63:101174.
Many aspects of crew resource management in aviation, such as the sterile cockpit, are used in healthcare to increase situational awareness (SA) and decrease human error. The situational awareness of paramedics in one US city was measured before and after receiving a targeted educational program on situational awareness. There was a statistically significant increase in SA following the intervention, although additional research is needed with larger cohorts.
Fitzgerald KM, Banerjee TR, Starmer AJ, et al. Pediatr Qual Saf. 2022;7:e539.
I-PASS is a structured handoff tool designed to improve communication between teams at change-of-shift or between care settings. This children’s hospital implemented an I-PASS program to improve communication between attending physicians and safety culture. One year after the program was introduced, all observed handoffs included all five elements of I-PASS and the duration of handoff did not change. Additionally, the “handoff and transition score” on the Agency for Healthcare Quality (AHRQ) Hospital Survey on Patient Safety Culture improved.
Aljuaid J, Al-Moteri M. J Emerg Nurs. 2022;48:189-201.
Situational awareness is the degree to which perception of a situation matches reality, and the lack of situational awareness can result in decreased patient outcomes. This study measured nurses’ situational awareness immediately after inspection of a resuscitation cart. Importantly, researchers observed significant issues related to readiness preparedness, such as empty oxygen tanks, drained batteries, and equipment failures.
Marufu TC, Bower R, Hendron E, et al. J Pediatr Nurs. 2022;62:e139-e147.
Medication errors threaten patient safety and can result in adverse outcomes. This systematic review identified seven types of nursing interventions used to reduce medication administration errors in pediatric and neonatal patients: education programs, medication information services, clinical pharmacist involvement, double checking, barriers to reduce interruptions during drug calculation and preparation, use of smart pumps, and improvement strategies (e.g., checklists, process or policy changes). Meta-analysis pooling results from various types of interventions demonstrated a 64% reduction in medication administration errors.
Galatzan BJ, Carrington JM. Res Nurs Health. 2021;44:833-843.
During handoffs, nurses are exposed to a variety of interruptions and distractions which may lead to cognitive overload. Using natural language processing, researchers analyzed ten audio-recorded change of shift handoffs to estimate the cognitive load experienced by nurses. Nurses’ use of concise language has the potential to decrease cognitive overload and improve patient outcomes.
Ali A, Miller MR, Cameron S, et al. Pediatr Emerg Care. 2022;38:207-212.
Interhospital transfer of critical care patients presents patient safety risks. This retrospective study compared adverse event rates between pediatric patient transport both with, and without, parent or family presence. Adverse event rates were not significantly impacted by parental presence.
Lafferty M, Harrod M, Krein SL, et al. J Am Med Inform Assoc. 2021;28:28(12).
Use of one-way communication technologies, such as pagers, in hospitals have led to workarounds to improve communication. Through observation, shadowing, interviews, and focus groups with nurses and physicians, this study describes antecedents, types, and effects of workarounds and their potential impact on patient safety.
Berdot S, Vilfaillot A, Bézie Y, et al. BMC Nurs. 2021;20:153.
Interruptions have been identified as a common source of medication errors. In this study of the effectiveness of a “do not interrupt” vest worn by nurses from medication preparation to administration, neither medication administration error or interruption rates improved.
Winters BD, Slota JM, Bilimoria KY. JAMA. 2021;326:1207-1208.
Alarm fatigue is a pervasive contributor to distractions and error. This discussion examines how, while minimizing nuisance alarms is important, those efforts need to be accompanied by safety culture enhancements to realize lasting progress toward alarm reduction.
Boquet A, Cohen T, Diljohn F, et al. J Patient Saf. 2021;17:e534-e539.
This study classified flow disruptions affecting the anesthesia team during cardiothoracic surgeries. Disruptions were classified into one of six human factors categories: communication, coordination, equipment issues, interruptions, layout, and usability. Interruptions accounted for nearly 40% of disruptions (e.g., events related to alerts, distractions, searching activity, spilling/dropping, teaching moment).