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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 3476 Results
Food and Drug Administration, Institute for Safe Medication Practices.
This fellowship program provides clinicians with learning opportunities at the Institute for Safe Medication Practices and the US Food and Drug Administration. The appointment consists of a pair of successive 6-month positions designed to provide experience in both system improvement and regulatory approaches to enhance medication safety. The process for submitting applications is open until March 31, 2023.
Hoffmann DE, Fillingim RB, Veasley C. J Law Med Ethics. 2022;50:519-541.
Women’s pain has been underestimated compared to men’s pain, and treatments differ based on gender. This commentary revisits the findings from the 2001 article The Girl Who Cried Pain: A Bias Against Women in the Treatment of Pain. The authors state progress has been made in the past 20 years, but disparities still exist. Additional research is needed, particularly into chronic pain conditions that are more common in women.
Gómez-Pérez V, Escrivá Peiró D, Sancho-Cantus D, et al. Healthcare (Basel). 2023;11:263.
The redeployment of clinicians at the beginning of the COVID-19 public health emergency necessitated rapid training of staff, particularly those assigned to the intensive care unit (ICU). This review identified effective in-situ simulations that could be used in ICUs to restore and sustain patient safety following the COVID-19 pandemic. The in-situ simulations were able to detect latent safety threats and improve patient safety culture, interprofessional communication, and system organization.
Patient safety is a dynamic discipline that adjusts regularly to address clinical, organizational and policy changes, and disruptions. This webinar series will provide insights on a variety of strategies and experiences to enhance care. The February offerings will feature two sessions led by Dr Gerald Hickson on professionalism and system accountability.

Chicago, IL: American College of Graduate Medical Education.

Lewis Blackman was a young man who lost his life to medical error when the severity of his condition after elective surgery was unrecognized by clinicians caring for him. This award will acknowledge residents and fellows engaged in developing educational programs on patient safety. Nominations for the 2024 award cycle are due March 15, 2023.
Klasen JM, Beck J, Randall CL, et al. Acad Pediatr. 2022;Epub Nov 25.
As part of clinical learning, residents and trainees are sometimes allowed to make supervised mistakes when patient safety is not at risk. In this study, pediatric hospitalists describe potential benefits and risks of allowing failure, the process of allowing or interrupting failure, and how they decide to allow failure to happen. Consistent with previous research, patient, trainee, team, and institutional factors were identified. Additionally, caregiver/parent factors were noted.
Hwang J, Kelz RR. BMJ Qual Saf. 2023;32:61-64.
Patient safety improvements must consider the complexities of care delivery to achieve lasting change. This commentary discusses recent evidence examining the effect of duty hour limit adjustments. The authors highlight challenges regarding research design on this medical education policy change and how it affects learner and patient experience. They suggest caution in applying the study conclusions. 
Institute for Safe Medication Practices.
These educational programs with the Institute for Safe Medication Practices (ISMP) are for clinicians who wish to expand their practical knowledge of medication error prevention. The application process for the 2023-2024 fellowships will close March 31, 2023.
WebM&M Case February 1, 2023

These cases describe the rare but dangerous complication of hematoma following neck surgery. The first case involves a patient with a history of spinal stenosis who was admitted for elective cervical discectomy and cervical disc arthroplasty who went into cardiopulmonary arrest three days post-discharge and could not be intubated due to excessive airway swelling and could not be resuscitated. Autopsy revealed a large hematoma at the operative site, causing compression of the upper airway, which was the suspected cause of respiratory and cardiac arrest.

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.
Kwon CS, Duzyj C. Am J Perinatol. 2022;Epub Dec 30.
Effective teamwork is critical for patient safety and numerous training strategies exist for improving team dynamics. The labor and delivery unit of an American hospital offered Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) training to all physicians and nurses on the ward, and assessed perceptions of teamwork and safety both before and six months after training. Results were mixed, and physician and nurse perceptions of safety significantly differed.

Institute for Healthcare Improvement. Gaylord National Resort and Convention Center, National Harbor, MD, May 22–24, 2023.

This annual conference will host pre-session workshops, panels, and presentations covering a variety of patient safety topics that align with the national agenda for patient safety improvement such as learning systems and leadership. Sessions will take place in-person.
Gillissen A, Kochanek T, Zupanic M, et al. Diagnosis (Berl). 2022;Epub Nov 9.
Medical students do not always feel competent when it comes to patient safety concepts. In this study of German medical students, most understood the importance of patient safety, though few could identify concrete patient safety topics, such as near miss events or conditions that contribute to errors. Incorporating patient safety formally into medical education could improve students’ competence in these concepts.

National Quality Forum. Omni Shoreham Hotel, Washington DC, February 20-22, 2023.

This hybrid annual conference will focus motivating innovation through effective measurement in health care. The content will be directed toward a multidisciplinary audience to support healthcare improvement in all communities in areas such as maternal outcomes and equity. The session will feature a presentation of the John Eisenberg award winners and Atul Gawande as a key note speaker.
Armstrong Institute for Patient Safety and Quality.
The comprehensive unit-based safety program (CUSP) approach emphasizes improving safety culture through a continuous process of reporting and learning from errors, improving teamwork, and engaging staff at all levels in safety efforts. Available on demand and live, this session covers how to utilize CUSP, including understanding and addressing challenges to implementation. The next virtual session will be held April 18-19, 2023.
Curated Libraries
January 19, 2023
The Primary-Care Research in Diagnosis Errors (PRIDE) Learning Network was a Boston-based national effort to improve diagnostic safety. Hosted by the State of Massachusetts’ Betsy Lehman Center, it was led by the Harvard Brigham and Women’s Center for Patient Safety Research and Practice with funding from the Gordon and Betty Moore Foundation. ...

Institute for Healthcare Improvement. Mar 14 - May 16, 2023.

Root cause analysis (RCA) is a widely recognized retrospective strategy for learning from failure that is challenging to implement. This series of webinars will feature an innovative approach to RCA that expands on the concept to facilitate its use in incident investigations. Instructors for the series will include Dr. Terry Fairbanks and Dr. Tejal K. Gandhi.

Indraprastha Apollo Hospitals. The Taj Palace, New Delhi, India. February 13-14, 2023.

This multidisciplinary international conference is designed around the theme of “Dream, Design, Dare.” Topics to be covered include strategic planning for improvement, artificial intelligence, and technologies as tools for safety care, and a peer exchange initiative to generate safety learnings.
Armstrong-Mensah E, Rasheed N, Williams D, et al. J Racial Ethn Health Disparities. 2022;Epub Nov 4.
Black patients who experience racism from their providers report receiving lower quality of care. Black public health students were asked about racist behaviors exhibited by their healthcare providers and the impacts the behaviors had on their care. The students recommend education and accountability to reduce providers’ racist attitudes, as well as increasing the number of Black clinicians.