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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 964 Results

Collaborative for Accountability and Improvement.  January 26, 2023, 2:00-3:00 PM (eastern).

Root cause analysis (RCA) is a recognized approach to examining failures by identifying causal factors to define improvement effort. This session will discuss challenges to the effective use of RCA results and examine an approach to present them that supports effective improvement action.

Agency for Healthcare Research and Quality. Fed Register. December 12, 2022;87:76046-76048.

Partnerships are needed to motivate, design, and implement lasting innovation in complex situations. This announcement calls for stakeholder insights on the work of the National Healthcare System Action Alliance to Advance Patient Safety and how it can best realize its mission and goals. The deadline for submitting comments is January 26, 2023.

Federal Office of Public Health. 2m2c Convention Centre, Montreux, Switzerland, February 23-24, 2023.

Medical errors continue to cause harm worldwide despite the planning and efforts to reduce them. This bi-yearly session will feature topics exploring the theme of “Less Harm, Better Care – from Resolution to Implementation.” It will cover weaknesses in improvement initiative implementation surfaced by the COVID-19 pandemic and offer approaches for addressing unsustainable program launches and implementation practices.
Mandel KE, Cady SH. BMJ Qual Saf. 2022;31:860-866.
Successful quality improvement (QI) initiatives should encourage change at the individual, team, and organizational levels. The authors of this article summarize the “self-limiting cascade” of quality improvement approaches, whereby QI programs prioritize process-technical strengths (e.g., quality metrics, “zero harm” goals) over participants’ emotional experience and sociotechnical design elements, which can ultimately hinder program performance.
Derdowski LA, Mathisen GE. Safety Sci. 2022;157:105948.
Work-related psychosocial factors may increase or decrease the risk of accidents in high-risk industries (e.g., nuclear, mining, healthcare). Using the Job Demands-Resources (JD-R) framework as a starting point, associations between job demands and resources, and between safety behaviors and outcomes were evaluated. Most studies report on the link between psychosocial factors and safety behavior (e.g., job stress or exhaustion can precede negative safety behavior).
Gogalniceanu P, Karydis N, Costan V-V, et al. J Am Coll Surg. 2022;235:612-623.
Safety strategies from high-reliability industries such as aviation and nuclear power are frequently adapted for healthcare. In this study, pilots described crisis preparedness strategies, which surgical safety experts then developed into a framework consisting of six behavioral interventions: anticipate threats, briefing, checklists, drill rehearsal, individual and team empowerment, and debriefing. An earlier study by the authors describes the second phase in managing crisis: crisis recovery.
Cakir MS, Wardman JK, Trautrims A. Risk Anal. 2022;Epub Oct 19.
Transparency, communication, and value alignment between staff and leaders increase staff trust and comfort in speaking up about concerns. This study describes the relationship of employees’ perception of ethical leadership (manager sets an example of ethical behavior), safety voice (comfort speaking up about COVID-19), ethical ambiguity regarding work responsibilities, and risk perception of coronavirus. Employees who rated their leaders as behaving more ethically were more comfortable speaking up about COVID-19 concerns.
Horvath D, Keith N, Klamar A, et al. J Bus Psychol. 2022;Epub Jul 26.
Error management, as opposed to error avoidance, has been shown to improve transfer of skills from training to practice. This study compared two interventions to induce error management (direct or indirect encouragement to learn from errors) and error avoidance. As hypothesized, participants in the error management groups performed better, particularly those in the indirect error management intervention.
Karanikas N, Khan SR, Baker PRA, et al. Safety Sci. 2022;156:105906.
Some patient safety interventions, such as checklists, are adapted or borrowed from other industries, such as aviation. This literature review focused on safety interventions developed in one context then implemented in another, such as healthcare. Healthcare was the largest sector represented, with 20 of the 73 included studies.

Dixon-Woods M, Martin G, eds. Cambridge, UK: Cambridge University Press; 2022.

Improvement activities are complex initiatives that require synergistic actions by organizations to be sustained. This evolving series provides background, evidence, and discussion on interdisciplinary strategies known to affect quality and safety such as implementation science, collaboration, positive deviance, and culture change.
Van Wassenhove W, Foussard C, Dekker SWA, et al. Safety Sci. 2022;154:105835.
Proficient safety professionals are the cornerstone of effective patient safety programs. In this study, safety professionals provided insights about theoretical factors influencing the role of safety professionals in healthcare (e.g., legal regulation, organizational context, safety culture).

Farnborough, UK: Healthcare Safety Investigation Branch; 2022.

Distinct individual skills and organizational factors strengthen patient safety incident analysis efforts. This series of educational video modules encapsulates a curriculum for investigation teams associated with a national United Kingdom program. It covers topics such as safety science and analysis initiative strategy.
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.

President’s Council of Advisors on Science and Technology. Washington, DC: White House; September 21, 2022.

National efforts are required to adjust the health care system and embed safety in programs and processes. Speakers participating in this webinar discussed the impact of errors on families, adverse event prevalence, aviation safety lessons, nursing’s improvement role, the current state of patient safety and what needs to be done to reduce the impact and associated cost of harm.
Perspective on Safety September 28, 2022

Special thanks to Freya Spielberg, MD, MPH, Founder and CEO of Urgent Wellness LLC in Washington, DC; and Jack Westfall, MD, MPH, Director of the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, for their thoughtful interviews on the topic of Primary Care and Patient Safety, which helped lay the groundwork for this Perspective.

Perspective on Safety September 28, 2022

Jack Westfall, MD MPH, is a retired professor from the University of Colorado School of Medicine and Former Director of the Robert Graham Center. We spoke with him about the role of primary care in the health and well-being of individuals, the hallmarks of high quality primary care and opportunities of primary care providers to enhance or promote patient safety.

Brown TH, Homan PA. Health Serv Res. 2022;57:443-447.
Structural racism, from race-adjusted algorithms to biased machine learning, contributes to and exacerbates health inequities. This commentary calls for developing valid measures of structural racism and a publicly available data infrastructure for researchers. A related study examined the relationship between structural racism and birth outcomes between Black and white patients in Minnesota.