Skip to main content

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.

Search All Content

Search Tips
Save
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Additional Filters
Displaying 1 - 20 of 919 Results
Dykes PC, Curtin-Bowen M, Lipsitz S, et al. JAMA Health Forum. 2023;4:e225125.
Patient falls are associated with poorer clinical outcomes, and increased costs to the health system. This study describes the economic costs of implementing the Fall Tailoring Interventions for Patient Safety (Fall TIPS) Program in eight American hospitals. Results show the Fall TIPS program reduced falls by 19%, avoiding over $14,000 of costs per 1,000 patient days.
Bushuven S, Trifunovic-Koenig M, Bentele M, et al. Int J Environ Res Public Health. 2022;19:16016.
Healthcare workers (HCWs) who are involved in serious adverse events may feel traumatized by those events, and many organizations have implemented “second victim” training programs to support their workers. This study sought to understand HCWs’ motivations to attend such trainings and a potential association with overconfidence. Understanding the association may help organizations develop effective training programs and increase motivation to attend them.
Corby S, Ash JS, Florig ST, et al. J Gen Intern Med. 2022;Epub Nov 16.
Medical scribes are increasingly being utilized to reduce the time burden on clinicians for electronic health record (EHR) documentation. In this secondary analysis, researchers identified three themes for safe use of medical scribes: communication aspects, teamwork efforts, and provider characteristics.
Abrams R, Conolly A, Rowland E, et al. J Adv Nurs. 2023;Epub Jan 16.
Speaking up about safety concerns is an important component of safety culture. In this study, nurses in a variety of fields shared their experiences with speaking up during the COVID-19 pandemic. Three themes emerged: the ability to speak up or not, anticipated consequences of speaking up, and responses, or lack thereof, from managers.
Woodier N, Burnett C, Moppett I. J Patient Saf. 2022;19:42-47.
Reporting and learning from adverse events is a core patient safety activity. Findings from this scoping review indicate limited evidence demonstrating that reporting and learning from near-miss events improves patient safety. The authors suggest that future research further explore this relationship and establish the effectiveness of system-level actions to avoid near misses.
Newcomer CA. N Engl J Med. 2023;388:198-200.
Children with complex care needs present unique challenges for both parents and clinical teams. This commentary offers a physician-parent’s perspective on weaknesses in the care system that decreased medication safety for her child and also decreased patient-centeredness, including lack of a respect for the family as care team members.

DePeau-Wilson M. MedPage Today. January 13, 2023.

The use of anesthesia in ambulatory settings presents both advantage and risk to patients and clinicians. This article discusses evidence defining these issues. It suggests that improved collaboration with anesthesiologists represents opportunities for nonoperating room anesthesia safety.

Collaborative for Accountability and Improvement Policy Committee. Seattle, WA: University of Washington; 2022

Communication and resolution programs (CRP) show promise for improving patient and clinician communication after a harmful preventable adverse event. This tool provides a framework for organizational messaging on CRPs for patients and families.
Hashemian SM, Triantis K. Safety Sci. 2023;159:106045.
Production pressures can inhibit effective decision-making and threaten patient safety. This systematic review examines the effects of production pressures in sociotechnical systems and discusses the need for future research to develop and implement systems to monitor and control production pressures.
Bloomer A, Wally M, Bailey G, et al. Geriatr Orthop Surg Rehabil. 2022;13:215145932211256.
Opioid use by older adults increases the risk of falls. This study examined electronic health record data to determine the proportion of older adults presenting to the emergency room or urgent care due to a fall who receive an opioid prescription, particularly those with at least one risk factor for misuse. Nearly one third of patients received a prescription for an opioid and/or benzodiazepine, and 11% had at least one risk factor for misuse.

REPAIR Project Steering Committee. Acad Med. 2022;97(12):1753-1759. 

The REPAIR (REParations and Anti-Institutional Racism) Project at the University of California, San Francisco, aims to repair racial injustices in medical care and research. This article discusses the development of the initiative, the three annual themes (reparations, abolition, decolonization), and outcomes from its first year.
Danielson B. Health Affairs. 2022;41:1681-1685.
Racism is a patient safety issue that is gaining the increased attention needed to clarify, understand, and reduce its impact. This commentary draws from a primary care pediatrician’s experience to illustrate how latent systemic racism influences decision making to affect a Black mother’s ability to care for her child with complex care needs.
Smith WR, Valrie C, Sisler I. Hematol Oncol Clin North Am. 2022;36:1063-1076.
Racism exacerbates health disparities and threatens patient safety. This article summarizes the relationship between structural racism and health disparities in the United States and highlights how racism impacts health care delivery and health outcomes for patients with sickle cell disease.
Portland, OR: Oregon Patient Safety Commission.
This site provides data and analysis from two Oregon Patient Safety Commission patient safety initiatives: the Patient Safety Reporting Program (PSRP) and Early Discussion and Resolution (EDR) effort. The review of 2021 PSRP data discusses the impact of the state adverse event reporting program and upcoming initiative to examine how organizational safety effort prioritization affects care in Oregon. The 2022 EDR analysis discusses the uptake of the program to generate conversations with patients and providers after a patient safety incident occurred.
Institute for Healthcare Improvement.
This website provides resources for promoting patient safety during Patient Safety Awareness Week. The 2023 observance will be held March 12-18. 
Kaplan HM, Birnbaum JF, Kulkarni PA. Diagnosis (Berl). 2022;9:421-429.
Premature diagnostic closure, also called anchoring bias, relies on initial diagnostic impression without continuing to explore differential diagnoses. This commentary proposes a cognitive forcing strategy of “endpoint diagnosis,” or continuing to ask “why” until additional diagnostic evaluations have been exhausted. The authors describe four common contexts when endpoint diagnoses are not pursued or reached.
Gotlieb R, Praska C, Hendrickson MA, et al. JAMA Netw Open. 2022;5:e2242972.
Ensuring patients understand their diagnosis and care plan is important to achieving optimal outcomes. However, patients routinely report not understanding what their provider has told them. In this study, adults were asked for their understanding of jargon clinicians regularly use (“negative” test results, NPO) and a corresponding statement without jargon (“you do not have an infection”, “nothing by mouth”). Some jargon was better understood (“negative”) than other jargon (“occult infection”). Participant demographics were not significantly associated with understanding jargon.
Sheikh A, Coleman JJ, Chuter A, et al. Programme Grants Appl Res. 2022;10:1-196.
Electronic prescribing (e-prescribing) is an established medication error reduction mechanism. This review analyzed experiences in the United Kingdom to understand strengths and weaknesses in e-prescribing. The work concluded that e-prescribing did improve safety in the UK and that the implementation and use of the system was a complex endeavor. The effort produced an accompanying toolkit to assist organizations in e-prescribing system decision making.