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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 33 Results
Krvavac S, Jansson B, Bukholm IRK, et al. Int J Environ Res Public Health. 2022;19:10686.
Inpatient suicide is sentinel event. This study examined treatment patterns among patients undergoing inpatient or outpatient psychiatric treatment who died by suicide. The research team found that patients who were primarily treated with medications were less likely to be sufficiently monitored, whereas patients who received both psychotherapy and medication were more likely to receive inadequate treatment.
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.

National Confidential Inquiry into Suicide and Safety in Mental Health. Manchester, UK: University of Manchester; May 31, 2021

System failures require multifactorial assessment to install targeted improvements. This toolkit examines 10 areas of focus for organizations to assess the safety of mental health services in emergency and primary care settings to minimize patient suicide and self-harm. Areas of focus include post-discharge follow-up, admissions, and family engagement.
Alshehri GH, Ashcroft DM, Nguyen J, et al. Drug Saf. 2021;44:877-888.
Adverse drug events (ADE) can occur in any healthcare setting. Using retrospective record review from three mental health hospitals, clinical pharmacists confirmed that ADEs were common, and that nearly one-fifth of those were considered preventable.
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.
Tyler N, Wright N, Panagioti M, et al. Health Expect. 2021;24:185-194.
Transitions of care represent a vulnerable time for patients. This survey found that safety in mental healthcare transitions (hospital to community) is perceived differently by patients, families, and healthcare professionals. While clinical indicators (e.g., suicide, self-harm, and risk of adverse drug events) are important, patients and families also highlighted the social elements of transitional safety (e.g., loneliness, emotional readiness for change).
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.   
Mills PD, Soncrant C, Gunnar W. BMJ Qual Saf. 2021;30:567-576.
This retrospective analysis used root cause analysis reports of suicide events in VA hospitals to characterize suicide attempts and deaths and provide prevention recommendations. Recommendations include avoidance of environmental hazards, medication monitoring, control of firearms, and close observation.
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.
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.
Quinlivan L, Littlewood DL, Webb RT, et al. J Mental Health. 2020;29:1-5.
This editorial proposes adapting a patient safety paradigm – Safety-I or Safety-II – to provide insights into suicidal behavioral, as it is a preventable outcome and health services play an important role in reducing its incidence. The new paradigm – Safety III – would incorporate on health services research combined with ethnography and strong patient/public involvement.
Thibaut BI, Dewa LH, Ramtale SC, et al. BMJ Open. 2019;9:e030230.
This exploratory systematic review aimed to describe the state of the research on patient safety in inpatient mental health settings. Authors included 364 papers, representing 31 countries and data from over 150,000 participants. The existing research base was categorized into ten broad safety categories – interpersonal violence, coercive interventions, safety culture, harm to self, safety of the physical environment, medication safety, unauthorized leave, clinical decision making, falls, and infection prevention/control; papers were of varying quality with the majority of papers assessed as “fair”. The authors note that several areas of patient safety in inpatient mental health are particularly understudied, such as suicide, as the review only yielded one study meeting inclusion criteria.
Archer S, Thibaut BI, Dewa LH, et al. J Psychiatr Ment Health Nurs. 2019;27:211-223.
Researchers conducted focus groups in this qualitative study of staff in mental healthcare settings and assessed the barriers and facilitators to incident reporting. The authors identified unique challenges to incident reporting in mental health, including the incidence of violence and aggressive behavior. Participants often underreported violent or aggressive events because they attributed the behavior to the patient’s diagnosis, and cited dissatisfaction with how reported incidents were handled by police.
Schwappach DLB, Niederhauser A.  Int J Ment Health Nurs. 2019;28:1363-1373.
This study focused on healthcare workers speaking-up behavior in six psychiatric hospitals in Switzerland. The authors found significant differences in speaking-up despite having moderate to high scores on items that were associated with psychological safety. Although nurses reported patient safety concerns more frequently, they also remained silent more often compared with psychologists and physicians, indicating they may feel less psychological safety.
Keers RN, Plácido M, Bennett K, et al. PLoS One. 2018;13:e0206233.
This interview study used a human factors method, the critical incident technique, to identify underlying factors in medication administration errors in a mental health inpatient facility. The team identified multiple interconnected vulnerabilities, including inadequate staffing, interruptions, and communication challenges. The findings underscore the persistence of widely documented medication safety administration concerns.
Newcastle upon Tyne, UK: Care Quality Commission; December 2018.
The term never events was originally coined to describe rare, devastating, and preventable events. This report provides an analysis of National Health Service (NHS) efforts to optimize use of alerts, guidance, and recommendations to prevent never events. The investigation found that NHS staff feel unsupported by training, challenged by complex processes of care to practice safely, and uncertainty regarding improvement roles at the system level.
O'Connor K, Neff DM, Pitman S. Eur Psychiatry. 2018;53:74-99.
Clinician burnout has been associated with decreased job satisfaction. Burnout may also be detrimental to patient safety. This systematic review and meta-analysis found high rates of burnout among mental health professionals. The authors recommend strategies to address burnout including promoting professional autonomy, developing teamwork, and providing quality clinical supervision.
Patel R, Chesney E, Cullen AE, et al. Br J Psychiatry. 2016;209:29-34.
Multiple studies have documented that patients with various conditions admitted over the weekend have worse outcomes than those admitted on a weekday. This large retrospective study did not find any difference in inpatient mortality for patients admitted to a psychiatric ward on the weekend. However, these patients had shorter admissions and were more likely to be readmitted, and the authors felt that these findings were most likely attributable to inherent differences in the types of psychiatric patients admitted on weekends.