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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 802 Results
Essex R, Weldon SM, Thompson T, et al. Health Serv Res. 2022;57:1218-1234.
A systematic review in early 2022 revealed healthcare worker strikes may negatively impact patient safety but also result in long-term benefits. This review by the same authors explores the impact of strikes on in-hospital and population mortality. None of the 11 studies examining in-hospital mortality reported a significant difference between mortality during the strike compared to the control period. Similarly, there was no difference in population mortality.
Carmack A, Valleru J, Randall KH, et al. Jt Comm J Qual Patient Saf. 2022;Epub Sep 30.
Retained surgical items (RSI) are a never event, a serious and preventable event. After experiencing a high rate of RSIs, this United States health system implemented a bundle to reduce RSI, improve near-miss reporting, and increase process reliability in operating rooms. The bundle consisted of five elements: surgical stop, surgical debrief, visual counters, imaging, and reporting.
Pun BT, Jun J, Tan A, et al. Am J Crit Care. 2022;31:443-451.
Team collaboration is an essential part of ensuring patient safety in acute care settings. This survey of care team members (including nurses, physicians, pharmacists, respiratory therapists, and rehabilitation therapists) assessed teamwork and collaboration across 68 intensive care units (ICUs). Teamwork and work environment were rated favorably but care coordination and meaningful recognition were rated least favorably.
Rosen A, Carter D, Applebaum JR, et al. J Patient Saf. 2022;18:e1219-e1225.
The COVID-19 pandemic had wide-ranging impacts on care delivery and patient safety. This study examined the relationship between critical care clinician experiences related to patient safety during the pandemic and COVID-19 caseloads during the pandemic. Findings suggest that as COVID-19 caseloads increased, clinicians were more likely to perceive care as less safe.
Auschra C, Asaad E, Sydow J, et al. J Patient Saf. 2022;18:e1211-e1218.
Health systems are increasingly aiming to become high-reliability organizations, able to operate for an extended period without serious accidents. This systematic review identified 75 studies reporting on health systems’ interventions to improve reliability, the goals of the interventions, and how achievement of the goals was measured. The six goals of Crossing the Quality Chasm were used to categorize studies. Most studies focused solely or in part on safety; only ten focused solely on one of the other five goals.
Perspective on Safety November 16, 2022

Dr. Pascale Carayon, PhD, is a professor emerita in the Department of Industrial and Systems Engineering and the founding director of the Wisconsin Institute for Healthcare Systems Engineering (WIHSE). Dr. Nicole Werner, PhD, is an associate professor in the Department of Health and Wellness Design at the Indiana University School of Public Health-Bloomington. We spoke with both of them about the role of human factors engineering has in improving healthcare delivery and its role in patient safety.

Wilson M-A, Sinno M, Hacker Teper M, et al. J Patient Saf. 2022;18:680-685.
Achieving zero preventable harm is an ongoing goal for health systems. In this study, researchers developed a five-part strategy to achieve high-reliability and eliminate preventable harm at one regional health system in Canada – (1) engage leadership, (2) develop an organization-specific patient safety framework, (3) monitor specific quality aims (e.g., high-risk, high-cost areas), (4) standardize the incident review process, including the use of root cause analysis, and (5) communicate progress to staff in real-time via electronic dashboards. One-year post-implementation, researchers observed an increase in patient safety incident reporting and improvements in safety culture, as well as decreases in adverse events such as falls, pressure injuries and healthcare-acquired infections.
Patient Safety Innovation November 16, 2022

While electronic health records, computerized provider order entry, and clinical decision support have increased patient safety, they can also create new challenges such as alert fatigue. One medical center developed and implemented a program to identify and reduce the number of alerts clinicians encounter every day. 

Patient Safety Innovation November 16, 2022

Appropriate follow-up of incidental abnormal radiological findings is an ongoing patient safety challenge. Inadequate follow-up can contribute to missed or delayed diagnosis, potentially resulting in poorer patient outcomes. This study describes implementation of an electronic health record-based referral system for patients with incidental radiologic finding in the emergency room. 

Tubic B, Finizia C, Zainal Kamil A, et al. Nurs Open. 2022;Epub Oct 31.
Interventions to increase patient engagement in safety are receiving increasing attention. In this study, patients were given a safety leaflet containing information about the patient can avoid adverse events during their hospital stay. Participants were overall satisfied about receiving information about their care but noted a lack of communication between healthcare personnel and patients regarding the safety leaflet.

Hare R, Tapia A, Tyler ER, Fan L, et al. Rockville, MD: Agency for Healthcare Research and Quality; October 2022. AHRQ Publication No. 22(23)-0066.

Instituting a culture of safety is fundamental to ensuring patient and staff safety. The AHRQ Hospital Survey on Patient Safety Culture (SOPS®) is a validated survey that has been widely used to assess patient safety culture since 2004. The 2022 report includes data from 400 hospitals. The highest “percent positive” composite measure scores included both effective teamwork and supervisor, manager, or clinical leader support for suggestions for improving patient safety, and addressing patient safety concerns. Overall, when asked to rate their unit/work area on patient safety, 67 percent of respondents rated their unit/work area as “Excellent” or “Very Good.”
McCain N, Ferguson T, Barry Hultquist T, et al. J Nurs Care Qual. 2022;Epub Aug 19.
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.
Kam AJ, Gonsalves CL, Nordlund SV, et al. BMC Emerg Med. 2022;22:152.
Debriefing after significant clinical events facilitates team-based communication, learning, and support. This study compared two post-resuscitation debriefing tools (Debriefing In Situ Conversation after Emergent Resuscitation Now [DISCERN] and Post-Code Pause [PCP]) following any intubation, resuscitation, or serious/unanticipated patient outcome in a children’s hospital. PCP was found to provide more emotional support and clinical learning, but there were no differences in the remaining categories.
WebM&M Case October 27, 2022

A 49-year-old woman presented to an Emergency Department (ED) with abdominal pain nine hours after discharge following outpatient laparoscopic left oophorectomy. The left oophorectomy procedure involved an umbilical port placed using an Optiport visual trocar, a suprapubic port, and two additional ports laterally.

Paydar-Darian N, Stack AM, Volpe D, et al. Pediatrics. 2022;Epub Oct 12.
Errors during the discharge process can lead to return visits and adverse health outcomes. This article describes the implementation of a new standardized discharge process (including a new checklist, provider huddle, and scripted caregiver education) at one children’s hospital. Over a 19-month period, implementation of the revised discharge process led to the elimination of preventable, discharge-related serious safety events and did not result in increased length-of-stay or return visits.
Wu G, Podlinski L, Wang C, et al. Jt Comm J Qual Patient Saf. 2022;48:665-673.
Simulation training is used to improve technical and nontechnical skills among healthcare teams. This study evaluated the impact of a one-hour interdisciplinary in situ simulation training on code response, teamwork, communication and comfort during intraoperative resuscitations. After simulation training, researchers noted improvements in technical skills of individuals and teams (e.g., CPR-related technical skills).
Loving VA, Nolan C, Bessel M. Jt Comm J Qual Patient Saf. 2022;48:599-608.
The Safety-II perspective emphasizes improving patient safety by focusing on what goes right in healthcare, rather than on errors or what goes wrong (Safety-I). This article describes the development, implementation, and evaluation of an organizational, asset-based quality improvement tool to complement existing practices (such as peer review and incident reporting) and provide an additional avenue to identify best practices and successful quality improvement initiatives.
Joseph MM, Mahajan P, Snow SK, et al. Pediatrics. 2022;Epub Oct 3.
Children with emergent care needs are often cared for in complex situations that can diminish safety. This joint policy statement updates preceding recommendations to enhance the safety of care to children presenting at the emergency department. It expands on the application of topics within a high-reliability framework focusing on leadership, managerial factors, and organizational factors that support safety culture and workforce empowerment to support safe emergency care for children.