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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 44 Results
Morris J, Schomerus G. Drug Alcohol Rev. 2023;42:1264-1268.
Stigma and bias in healthcare undermine patient safety. This article discusses how stigma associated with alcohol use can impede the delivery of quality health care and contribute to poor patient outcomes. 
Riblet NB, Soncrant C, Mills PD, et al. Mil Med. 2023;188:e3173-e3181.
Patient suicide is a sentinel event, and suicide among veterans has gained attention. In this retrospective analysis of suicide-related events reported to the Veterans Health Administration (VHA) National Center for Patient Safety between January 2018 and June 2022, researchers found that deficiencies in mental health treatment, communication challenges, and unsafe environments were the most common contributors to suicide-related events.
WebM&M Case March 29, 2023

An adult woman with a history of suicidal ideation was taking prescribed antidepressants, but later required admission to the hospital after overdosing on her prescribed medications. A consulting psychiatrist evaluated the patient but recommended sending her home on a benzodiazepine alone, under observation by her mother.

Vargas V, Blakeslee WW, Banas CA, et al. PLoS ONE. 2023;18:e0279903.
Medication reconciliation can help identify medication discrepancies during transitions of care. This study examined the impact of a complete medication history database to support pharmacist-led medication reconciliation and identification of medication discrepancies during the admission process for patients at one psychiatric hospital. A retrospective analysis identified 82 medication errors; 90% of these errors – primarily dosage discrepancies and omissions – could have led to patient harm if not corrected through pharmacist intervention.
McCain N, Ferguson T, Barry Hultquist T, et al. J Nurs Care Qual. 2023;38:26-32.
Daily huddles can improve team communication and awareness of safety incidents. This single-site study found that implementation of daily interdisciplinary huddles increased reporting of near-miss events and improved team satisfaction and perceived team communication, collaboration, and psychological safety.
Riblet NB, Varela M, Ashby W, et al. Jt Comm J Qual Patient Saf. 2022;48:503-512.
Preventing suicide among patients with a mental health diagnosis is a National Patient Safety goal. This study evaluated the impact of the WHO Brief Intervention and Contact (BIC) Program on suicide after psychiatric discharge at six Department of Veterans Affairs (VA) medical centers. After implementation, nearly 82% of patients exhibited positive treatment engagement. Participating healthcare staff reported that the program was easy to use and implement but noted that insufficient staffing and patient loss-to-follow-up can impede program success. A previous WebM&M case and commentary discusses suicide after discharge.

Rockville, MD: Substance Abuse and Mental Health Services Administration; 2022.  SAMHSA Publication No. PEP22-06-02-005.

Behavioral health workers are particularly susceptible to burnout, which sets the stage for unsafe care. This guide highlights organizational strategies to amend six thematic conditions in the behavioral health setting that degrade worker wellbeing: workload; control; reward, promotion, and career development; community; fairness; and values.
Berg SH, Rørtveit K, Walby FA, et al. BMC Health Serv Res. 2022;22:967.
Inpatient suicides are considered a never event. Based on patient and provider interviews and a literature review, this paper describes the development of resilience in inpatient psychiatric settings. The main theme is establishment of relationship of trust between patients and providers.
Barnes T, Fontaine T, Bautista C, et al. J Patient Saf. 2022;18:e704-e713.
Patient safety event taxonomies provide a standardized framework for data classification and analysis. This taxonomy for inpatient psychiatric care was developed from existing literature, national standards, and content experts to align with the common formats used by the institution’s event reporting system. Four domains (provision of care, patient actions, environment/equipment, and safety culture) were identified, along with categories, subcategories, and subcategory details.
Brierley-Jones L, Ramsey L, Canvin K, et al. Res Involv Engagem. 2022;8:8.
Patient engagement in safety efforts is encouraged, but patients are less often included as active participants in designing patient safety interventions. This review identified 52 studies that included mental health patients in the design, delivery, implementation, and/or evaluation of patient safety research. The authors argue that increased inclusion of patients in safety research may lead to development of higher quality safety interventions.
Perspective on Safety March 31, 2022

A psychologically safe environment for healthcare teams is desirable for optimal team performance, team member well-being, and favorable patient safety outcomes. This piece explores facilitators of and barriers to psychological safety across healthcare settings. Future research directions examining psychological safety in healthcare are discussed.

A psychologically safe environment for healthcare teams is desirable for optimal team performance, team member well-being, and favorable patient safety outcomes. This piece explores facilitators of and barriers to psychological safety across healthcare settings. Future research directions examining psychological safety in healthcare are discussed.

Anderson E, Mohr DC, Regenbogen I, et al. J Patient Saf. 2021;17:316-322.
Burnout and low staff morale have been associated with poor patient safety outcomes. This study focused on the association between organizational climate, burnout and morale, and the use of seclusion and restraints in inpatient psychiatric hospitals. The authors recommend that initiatives aimed at reducing restraints and seclusion in inpatient psychiatric facilities also include a component aimed at improving organizational climate and staff morale.
Mills PD, Watts BV, Hemphill RR. J Patient Saf. 2021;17:e423-e428.
Researchers reviewed 15 years of root cause analysis reports of all instances of suicide and suicide attempts on Veterans Health Administration (VHA) grounds. Forty-seven suicides or suicide attempts were identified, and primary root causes included communication breakdown and a need for improved suicide interventions. The paper includes recommended actions to address the root causes of attempted and completed patient suicides.
Alshehri GH, Keers RN, Carson-Stevens A, et al. J Patient Saf. 2021;17:341-351.
Medication errors are common in mental health hospitals. This study found medication administration and prescribing were the most common stages of medication error. Staff-, organizational-, patient-, and equipment-related factors were identified as contributing to medication safety incidents.
Mackenhauer J, Winsløv J-H, Holmskov J, et al. Crisis. 2021;43:307-314.
Prior research has found that patients who die by suicide often had recent contact with the healthcare setting. Based on a multi-year chart review at one institution, the authors concluded that suicide risk assessment and documentation in the heath record to be insufficient. The authors outline quality improvement recommendations focused on improving documentation, suicide assessment and intervention training, and improving communications with families, caregivers, and other health care providers.
Shao Q, Wang Y, Hou K, et al. J Adv Nurs. 2021;77:4005-4016.
Patient suicide in all settings is considered a never event. Nurses caring for the patient may experience negative psychological symptoms following inpatient suicide. This review identified five themes based on nurses’ psychological experiences: emotional experience, cognitive experience, coping strategies, self-reflection, and impact on self and practice. Hospital administrators should develop education and support programs to help nurses cope in the aftermath of inpatient suicide.  
Hunt DF, Bailey J, Lennox BR, et al. Int J Ment Health Syst. 2021;15:33.
Psychological safety has been widely studied in a variety of settings, clinical areas, and patient outcomes. This commentary lays out the benefits of safety culture and how it can be implemented organization-wide, with a particular focus on mental health organizations. Specific interventions are discussed, including family involvement, leadership communication, and simulation.
Berg SH, Rørtveit K, Walby FA, et al. BMJ Open. 2020;10:e040088.
Patient safety is an emerging focus within the mental health field. This qualitative study highlights three themes of perceived safe clinical care for patients in a suicidal crisis – being recognized as suicidal, receiving personalized treatment, and adapting care to meet fluctuating behaviors.   
Cutler NA, Sim J, Halcomb E, et al. J Clin Nurs. 2020;29:4379-4386.
An important element of providing patient-centered care is enhancing patient perceptions of safety. This qualitative study explored how nurses influence perceptions of safety among patients admitted for acute mental health care. Findings suggest that nurses can improve patients’ sense of safety by being available, responsive, and caring towards patients, while also focusing on management of risk.
Berzins K, Baker J, Louch G, et al. Health Expect. 2020;23:549-561.
This qualitative study interviewed patients and caregivers about their experiences and perceptions of safety within mental health services. These interviews identified a broad range of safety issues; the authors suggest that patient safety in mental health services could be expanded to include harm caused trying to access services and self-harm provoked by contact with, or rejection from, services.