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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 245 Results
Farrell TW, Hung WW, Unroe KT, et al. J Am Geriatr Soc. 2022;Epub Oct 19.
Research into the impact of racism on health outcomes has increased in recent years, but there has been less emphasis on ageism or the intersection of ageism and racism. This commentary highlights the ways racism (e.g., clinical algorithms), ageism (e.g., proposed measures to ration care) and the intersection of the two (increased morbidity and mortality of COVID-19 on older people of color) impacts health outcomes. Recommendations for current clinicians and health profession educators are provided.
M. Violato E. Can J Respir Ther. 2022;58:137-142.
Healthcare trainees and junior clinicians are often reluctant to speak up about safety concerns. This qualitative study found that simulation training to enhance speaking up behaviors had lasting effects among advanced care paramedics and respiratory therapists as they moved from training into practice. Respondents highlighted the importance of experience for speaking up and the benefits of high-impact simulation training.
Institute for Healthcare Improvement. March 8 - May 16, 2023.
Burnout among health care workers negatively affects system improvement. This webinar series will highlight strategies to establish a healthy work environment that strengthens teamwork, staff engagement, and resilience. Instructors include Dr. Donald Berwick and Derek Feeley.
AHA Team Training. January 12 - March 2, 2023.
The TeamSTEPPS program was developed to support effective communication and teamwork in health care. This online series will prepare participants to guide their organizations through implementation of the TeamSTEPPS program. It is designed for individuals that are new to TeamSTEPPS processes. 
Andraska EA, Phillips AR, Asaadi S, et al. J Surg Educ. 2022;Epub Oct 4.
Patients and clinicians may hold implicit gender biases and rate women clinicians more negatively. In this study, adverse event reports written about residents were reviewed to determine if resident gender was associated with different types and frequency of incident reports. The most comment complaint about men physicians involved a medical error, while the most common complaint type about women included a communication-related event. Additionally, women were more frequently identified by name only, without a title such as “doctor”.

Chicago, IL: The National Association for Healthcare Quality; 2022.

Quality and safety work requires distinct competencies to support effective action and systemic approaches to improvement. This report highlights areas of emphasis and weakness across quality domains and the need for health organization leadership to train and direct designated staff to realize quality and safety goals.
Lagu T, Haywood C, Reimold KE, et al. Health Aff (Millwood). 2022;41:1387-1395.
People with disabilities face barriers to safe, equitable care such as inaccessible equipment and facilities or provider bias. In this study, primary care and specialist physicians described challenges with caring for patients with disabilities. Many expressed explicit biases such as reluctance to care for people with disabilities, invest in accessible equipment, or obtain continuing education to provide appropriate care.
Liu SI, Shikar M, Gante E, et al. Crit Care Nurse. 2022;42:33-43.
Lack of communication between providers can contribute to failure to rescue. Following a series of deaths due in part to not identifying clinical deterioration in a timely manner and/or not escalating care, this surgical intensive care unit (SICU) implemented an interdisciplinary quality improvement intervention. The intervention consisted of educating nurses on conditions necessitating escalation, multidisciplinary rounds with night staff, and an escalation document in the electronic health record (EHR).
Soled KRS, Dimant OE, Tanguay J, et al. BMC Health Serv Res. 2022;22:1134.
Transgender and gender-diverse people can face discriminatory behaviors when accessing health care services. This qualitative study explored clinician perspectives with regard to practicing transgender health care. Findings indicate that stigma, gatekeeping, and knowledge deficits are barriers to high-quality care delivery but respondents also highlighted strategies for successful care delivery, including mentorship and use of a person-centered approach to care.
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.
Koch A, Kozhumam A. Health Promot Pract. 2022;23:555-559.
Racial biases have been uncovered in pediatric emergency care; for example, Black children are less likely to receive pain medication for appendicitis. This article describes the use of the Racism as Root Cause (RRC) framework to identify and reduce adultification (when children are perceived or treated as being older than they are) of Black children in emergency departments. RRC calls for systemic, rather than individual, efforts.
Rehder KJ, Adair KC, Eckert E, et al. J Patient Saf. 2022;Epub Aug 10.
Teamwork is an essential component of patient safety.  This cross-sectional study of 50,000 healthcare workers in four large US health systems found that the teamwork climate worsened during the COVID-19 pandemic. Survey findings indicate that healthcare facilities with worsening teamwork climate had corresponding decreases in other measured domains, including safety climate and healthcare worker well-being. The researchers suggest that healthcare organizations should proactively increase team-based training to reduce patient harm.

Garcia AD, Lopez X. AMA J Ethics. 2022;24(8):e753-e761. 

Implicit bias, discrimination, and stigmatization impact patient care. This article discusses unique care experience considerations for transgender people of color. It recommends actions individual clinicians can take to reduce inequalities, improve communications, and enhance patient-centeredness.
Sabin JA. N Engl J Med. 2022;387:105-107.
Implicit bias in clinicians can result in diagnostic errors and poor patient outcomes. This commentary outlines steps that individual clinicians, as well as healthcare systems, can take to reduce implicit bias and the resulting harm to patients.
Tajeu GS, Juarez L, Williams JH, et al. J Gen Intern Med. 2022;37:1970-1979.
Racial bias in physicians and nurses is known to have a negative impact on health outcomes in patients of color; however, less is known about how racial bias in other healthcare workers may impact patients. This study used the Burgess Model framework for racial bias intervention to develop online modules related to racial disparities, implicit bias, communication, and personal biases to help healthcare workers to reduce their implicit biases. The modules were positively received, and implicit pro-white bias was reduced in this group. Organizations may use a similar program to reduce implicit bias in their workforce.

Bryant A. UpToDate. June 28, 2022.

Implicit bias is progressively being discussed as a detractor to safe health care by fostering racial and ethnic inequities. This review examines the history of health inequities at the patient, provider, health care system, and cultural levels in obstetric and gynecologic care. It shares actions documented in the evidence base for application in health care to reduce the impact of implicit bias, with an eye toward maternal care

Institute for Safe Medication Practices.

A Just Culture supports effective reporting and learning from mistakes. This scholarship, inspired by the work and leadership of Judy Smetzer, former editor of the ISMP Medication Safety Alert! newsletter, will support three team or individual certifications in Just Culture practice. The application process is now closed.
Alpert AB, Mehringer JE, Orta SJ, et al. J Gen Intern Med. 2022;Epub May 31.
Transgender patients who experience or perceive bias when receiving care may avoid or delay seeking care in the future. In this study, transgender patients reported on their experiences in viewing their electronic health record (EHR). In line with previous studies, transgender patients reported experiencing harms in several ways, such as providers using the wrong pronouns, wrong name, or wrong gender marker. The structure of the EHR (e.g., no separate fields for sex and gender) itself also created barriers to quality care.

Villarosa L. New York, NT: Doubleday: 2022. ISBN 9780385544887. 

Health inequities are receiving increased attention as a patient safety issue. This book examines the persistent problem of systemic racism on the health of Black patients. It summarizes the evidence on how racism affects health care and discusses strategies for improvement such as reducing gaps in implicit bias content in curriculum.