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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 935 Results
Hwang J, Kelz RR. BMJ Qual Saf. 2023;32:61-64.
Patient safety improvements must consider the complexities of care delivery to achieve lasting change. This commentary discusses recent evidence examining the effect of duty hour limit adjustments. The authors highlight challenges regarding research design on this medical education policy change and how it affects learner and patient experience. They suggest caution in applying the study conclusions. 

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.  
Hoot NR, Barbosa TJ, Chan HK, et al. J Am Coll Emerg Physicians Open. 2022;3:e12849.
Previous research has suggested that increases in physician workloads can threaten patient safety. This retrospective study found that medical errors are higher among emergency medicine physicians with lower productivity, as measured by the number of patients seen per hour.
Pagani K, Lukac D, Olbricht SM, et al. Arch Dermatol Res. 2022;Epub Nov 10.
Delayed referrals from primary care providers to specialty care can lead to delayed diagnoses and patient harm. This retrospective analysis examined differences in timely versus delayed referrals for urgent skin cancer evaluations at one institution. Among 320 referrals occurring in 2018, 38% of evaluations occurred 31 days or more after the referral and nearly 11% of referrals were never completed. Delayed referrals were more common among patients who did not speak English and racial/ethnic minorities.
Essex R, Weldon SM, Thompson T, et al. Health Serv Res. 2022;57:1218-1234.
A systematic review in early 2022 revealed healthcare worker strikes may negatively impact patient safety but also result in long-term benefits. This review by the same authors explores the impact of strikes on in-hospital and population mortality. None of the 11 studies examining in-hospital mortality reported a significant difference between mortality during the strike compared to the control period. Similarly, there was no difference in population mortality.
Rosen A, Carter D, Applebaum JR, et al. J Patient Saf. 2022;18:e1219-e1225.
The COVID-19 pandemic had wide-ranging impacts on care delivery and patient safety. This study examined the relationship between critical care clinician experiences related to patient safety during the pandemic and COVID-19 caseloads during the pandemic. Findings suggest that as COVID-19 caseloads increased, clinicians were more likely to perceive care as less safe.
Sephien A, Reljic T, Jordan J, et al. Med Educ. 2022;Epub Oct 1.
The Accreditation Council for Graduate Medical Education (ACGME) includes work hour restrictions in its Common Program Requirements. The focus of this review is the impact of resident work hour restrictions on patient- and resident-level outcomes. Shorter shift hours were associated with some improved resident outcomes and but no association with patient outcomes.
Patient Safety Innovation November 16, 2022

Appropriate follow-up of incidental abnormal radiological findings is an ongoing patient safety challenge. Inadequate follow-up can contribute to missed or delayed diagnosis, potentially resulting in poorer patient outcomes. This study describes implementation of an electronic health record-based referral system for patients with incidental radiologic finding in the emergency room. 

Ibrahim M, Szeto WY, Gutsche J, et al. Ann Thorac Surg. 2022;114:626-635.
Reports of poor care in the media or public reporting systems can serve as an impetus to overhauling hospitals or hospital units. After several unexpected deaths and a drop in several rating systems, this cardiac surgery department launched a comprehensive quality improvement review. This paper describes the major changes made in the department, including role clarity and minimizing variation in 24/7 staffing.
Lauffenburger JC, Coll MD, Kim E, et al. Med Educ. 2022;56:1032-1041.
Medication errors can be common among medical trainees. Using semi-structured qualitative interviews, this study identified factors influencing suboptimal prescribing by medical residents during overnight coverage, including time pressures, perceived pressure and fear of judgement, clinical acuity, and communication issues between care team members.
Dehmoobad Sharifabadi A, Clarkin C, Doja A. BMJ Open. 2022;12:e063104.
Several countries have resident duty hour (RDH) restrictions and there are numerous publications examining the impact of RDH on patient safety. This study used two online discussion forums (one primarily in the United States and the other in Canada) to assess resident perceptions of RDH. Themes included its impact on residents’ education and clinician well-being, and, worryingly, discussions of not reporting RDH violations.
McCord JL, Lippincott CR, Abreu E, et al. Dimens Crit Care Nurs. 2022;41:347-356.
Workarounds can pose significant risks to patient safety. This systematic review including 13 studies found that nursing workarounds most often occurred due to challenges in using the electronic health record (EHR) system or during medication administration.
Giuliano KK, Blake JWC, Bittner NP, et al. J Patient Saf. 2022;18:553-558.
Intravenous (IV) smart pumps can improve medication administration safety, but usability issues can compromise that safety. This study compared actual use of smart pumps to the manufacturer’s requirements for operation. Adherence to requirements was low and the authors present several recommendations to smart pump manufacturers. The Institute for Safe Medication Practices issued guidelines for safe use of smart pumps that address several of these safety concerns.
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.
Martins MS, Lourenção DC de A, Pimentel RR da S, et al. BMJ Open. 2022;12:e060182.
In early 2020, hospitals, organizations, and expert panels released recommendations to maintain patient safety while reducing spread of COVID-19. This review summarized safety recommendations from 125 studies, reviews, and expert consensus documents. Recommendations were categorized into one of four areas: organization of health services, management of airways, sanitary and hygiene measures, and management of communication. Planning and implementing best practices based on these recommendations ensure safe care during COVID-19 and future pandemics.
Bagnasco A, Rossi S, Dasso N, et al. J Patient Saf. 2022;18:e903-e911.
Care left undone (also called missed care, unfinished care, and implicitly rationed care) is associated with lower perception of safety culture and increased adverse events. In this study, more than 2,200 pediatric nurses were asked about care tasks left undone in their most recent shift and a variety of environmental factors (e.g., perception of their work environment, risk of burnout). The most frequently omitted task was comfort/talk with patients, and the least frequently omitted task was pain management.
Lipori JP, Tu E, Shireman TI, et al. J Am Med Dir Assoc. 2022;23:1589.e1-1589.e10.
Despite evidence of associated adverse events, older adults in nursing homes are frequently prescribed potentially inappropriate medications (PIM). This review sought to identify facility and prescriber characteristics associated with PIM prescribing. Anti-psychotic medications were the focus of more than half of included studies, and were associated with low registered nurse staffing, for-profit facility status, and younger men. No study investigated prescriber characteristics.
Lim Fat GJ, Gopaul A, Pananos AD, et al. Geriatrics (Basel). 2022;7:81.
The risk of adverse events increases with prolonged hospital stays. This descriptive study examined adverse events among older patients with extended hospital admissions pending transfer to long-term care (LTC) settings at two Canadian hospitals. Analyses showed that patients were designated as “alternate level of care” (ALC) for an average of 56 days before transfer to LTC and adverse events such as falls and urinary tract infections were common.