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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 1204 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.
Newman B, Joseph K, McDonald FEJ, et al. Health Expect. 2022;Epub Oct 28.
Patient engagement focuses on involving patients in detecting adverse events, empowering patients to speak up, and emphasizing the patient’s role in a culture of safety. Young people ages 16-25 with experiences in cancer care, and staff who support young people with cancer were asked about their experiences with three types of patient engagement strategies. Four themes for engaging young people emerged, including empowerment, transparency, participatory culture, and flexibility. Across all these was a fifth theme of transition from youth to adult care.  
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.
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. 

Turner A, Morris R, McDonagh L, et al. Br J Gen Pract. 2022;Epub Sep 5.
Patient access to electronic health records can improve engagement in care. This qualitative study involving patients and staff at general practices in the United Kingdom highlighted unintended consequences of online access to health records, including challenges with patient health literacy, decreased quality of documentation, and increases in staff workload.
Costin I-C, Marcu LG. Crit Rev Oncol Hematol. 2022;178:103798.
Radiotherapy errors can be significant and sometimes fatal. This systematic review describes errors in patient set up based on verification systems, the immobilization devices used, and the patient’s positioning during breast cancer treatment. The advantages and drawbacks of the most common position verification systems, error types associated with immobilization systems, and the influence of treatment position are reviewed.
Skeff KM, Brown-Johnson CG, Asch SM, et al. J Healthc Manag. 2022;67:339-352.
Electronic health records (EHRs) can improve patient safety but can also contribute to physician burnout. This qualitative study involving physicians and medical trainees found that distress most often occurred when physicians were prioritizing systems-based practice (e.g., EHR-required documentation) over other professional activities, such as patient care, communication, and practice-based learning.  

Chicago, IL: The National Association for Healthcare Quality; 2022.

Quality and safety work requires distinct competencies to support effective action and systemic approaches to improvement. This report highlights areas of emphasis and weakness across quality domains and the need for health organization leadership to train and direct designated staff to realize quality and safety goals.
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.
Adamson HK, Foster B, Clarke R, et al. J Patient Saf. 2022;18:e1096-e1101.
Computed tomography (CT) scans are important diagnostic tools but can present serious dangers from overexposure to radiation. Researchers reviewed 133 radiation incidents reported to one NHS trust from 2015-2018. Reported events included radiation incidents, near-miss incidents, and repeat scans. Most events were investigated using a systems approach, and staff were encouraged to report all types of incidents, including near misses, to foster a culture of safety and enable learning.
Rockville, MD: Agency for Healthcare Research and Quality.
In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. The 2022 report discusses a decrease in life expectancy due to the COVID-19 pandemic. It also reviews the current status of special areas of interest such as maternity care, child and adolescent mental health, and substance abuse disorders. 
Fröding E, Vincent C, Andersson-Gäre B, et al. Arch Suicide Res. 2022;Epub Oct 19.
Earlier research shows many investigations into suicide deaths are conducted to fulfill regulatory requirements, rather than to improve suicide-prevention interventions. This review identified six problems with investigations (e.g., failure to consider deeper system perspective) and proposed a new model of investigation which considers suicide a patient harm.
Volpini ME, Lekx‐Toniolo K, Mahon R, et al. J Appl Clin Med Phys. 2022;Epub Aug 6.
The COVID-19 pandemic dramatically impacted the way that health care teams function. This study examined how COVID-19-related workflow changes affected reporting of medical errors and near misses occurring in one hospital’s radiation oncology program. After the onset of the COVID-19 pandemic, there was fewer incidents reported overall, but an increase in submissions related to poor documentation and communication.
Wong J, Lee S-Y, Sarkar U, et al. Am J Health Syst Pharm. 2022;Epub Sep 27.
Medication errors in ambulatory care settings represent an ongoing patient safety challenge. This study characterizes ambulatory care adverse drug events reported to a large patient safety organization between May 2012 and October 2018. Anticoagulants, antibiotics, hypoglycemics, and opioids were the most commonly involved medication classes. Contributing factors included prescribing errors, failure to review clinical contraindications or drug-drug interactions, and lack of patient education or communication.
Charles MA, Yackel EE, Mills PD, et al. J Patient Saf. 2022;18:686-691.
The first surge of the COVID-19 pandemic forced healthcare organizations to respond to patient safety issues in real-time. The Veterans Health Administration’s National Center for Patient Safety established two working groups to rapidly monitor quality and safety issues and make timely recommendations to staff. The formation, activities, and primary themes of safety issues are described.
Lagu T, Haywood C, Reimold KE, et al. Health Aff (Millwood). 2022;41:1387-1395.
People with disabilities face barriers to safe, equitable care such as inaccessible equipment and facilities or provider bias. In this study, primary care and specialist physicians described challenges with caring for patients with disabilities. Many expressed explicit biases such as reluctance to care for people with disabilities, invest in accessible equipment, or obtain continuing education to provide appropriate care.
Sacarny A, Safran E, Steffel M, et al. JAMA Health Forum. 2022;3:e223378.
Concurrent prescribing of opioids and benzodiazepines can put patients at increased risk of overdose. This randomized study found that pharmacist email alerts to clinicians caring for patients recently co-prescribed opioids and benzodiazepines did not reduce concurrent prescribing of these medications.