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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 - 13 of 13 Results
McMullen S, Panagioti M, Planner C, et al. Health Expect. 2023;26:2064-2074.
Caregivers and family members offer a unique perspective on patient safety. In this study, patient and caregiver stakeholders outlined the safety threats affecting patients discharged from mental health services and the well-being of caregivers as well as potential solutions. Participants highlighted approaches to improve caregiver involvement, patient and caregiver wellness and education, and the policy and system environments.
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.
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.
Tölli S, Kontio R, Partanen P, et al. Perspect Psychiatr Care. 2020;56:785-796.
This study used qualitative methods to understand the experiences of former psychiatric patients that nursing staff considered challenging and that resulted in behavior management interventions (e.g., aggression, self-harm, inappropriate sexual behavior). Interviewed patients cited various reasons for these challenging behaviors, including communication difficulties related to their psychiatric symptoms, stressful feelings such as frustration and fear, coercive nursing culture and restrictive nursing practices. Strategies for managing these behaviors are discussed, as well as core competencies for delivering care based on patients’ needs.
Salas E, Bisbey TM, Traylor AM, et al. Ann Rev Org Psychol Org Behav. 2020;7:283-313.
This review discusses the importance of teamwork in supporting safety, psychological states driving effective safety performance, organizational- and team-level characteristics impacting safety performance, and the role of teams in safety management.
Zaheer S, Ginsburg LR, Wong HJ, et al. BMJ Open Qual. 2018;7:e000433.
Establishing a culture of safety within health care organizations requires strong leadership support. This cross-sectional survey study of nurses, allied health professionals, and unit clerks working in the inpatient setting at a single hospital found that positive perceptions of senior leadership support for safety and positive perceptions of teamwork were associated with positive perceptions of patient safety. In addition, when staff perceived senior leadership support for safety to be lacking, the positive impact of direct managerial leadership on staff perceptions of patient safety was more pronounced.
WebM&M Case January 1, 2019
A woman with a history of psychiatric illness presented to the emergency department with agitation, hallucinations, tachycardia, and transient hypoxia. The consulting psychiatric resident attributed the tachycardia and hypoxia to her underlying agitation and admitted her to an inpatient psychiatric facility. Over the next few days, her tachycardia persisted and continued to be attributed to her psychiatric disease. On hospital day 5, the patient was found unresponsive and febrile, with worsening tachycardia, tachypnea, and hypoxia; she had diffuse myoclonus and increased muscle tone.
WebM&M Case October 1, 2010
A man prescribed a tricyclic antidepressant and an antipsychotic medication was found unconscious and unresponsive at home and was brought to the emergency department (ED). An electrocardiogram showed potentially dangerous heart rhythms.
WebM&M Case October 1, 2007
A code blue is called on an elderly man with a history of coronary artery disease, hypertension, and schizophrenia hospitalized on the inpatient psychiatry service. Housestaff covering the code team did not know where the service was located, and when the team arrived, they found their equipment to be incompatible with the leads on the patient.