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 3624 Results

When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)!

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WebM&M Case November 30, 2023

A 67-year-old man with well-controlled type 2 diabetes mellitus underwent elective cardiac resynchronization and defibrillator device (CRT-D) implantation. The procedure was successful and he was discharged the next day with instructions to resume his prior medications, including empagliflozin. He presented to the emergency department the following day where he was diagnosed with euglycemic diabetic ketoacidosis (eDKA) and he was transferred to the intensive care unit (ICU) for insulin infusion.

Digital health intervention on patient safety for children and parents: a scoping review.

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Park J, Jeon H, Choi EK. J Adv Nurs. 2023;Epub Nov 10.

Digital health tools are increasingly used to support the delivery of safe healthcare. This scoping review characterized 13 articles exploring the use of digital interventions intended to support patient safety among pediatric patients and their parents. Interventions were commonly delivered through mobile applications, web-based technologies, computer kiosks, and electronic health records, and focused on patient safety event prevention and risk management.

Public opinion of resident physician work hours in 2022.

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Weaver MD, Barger LK, Sullivan JP, et al. Sleep Health. 2023;Epub Nov 6.

Current Accreditation Council for Graduate Medical Education (ACGME) duty hour regulations limit resident work hours (no more than 80 hours per week or 24-28 consecutive hours on duty) in an effort to improve both resident and patient safety. This nationally representative survey found that over 90% of US adults disagree with the current duty hour policies, with 66% of respondents supporting additional limits on duty hours (to no more than 40 hours per week or 12 consecutive hours).

Certified Professional in Patient Safety Review Course.

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Institute for Healthcare Improvement. March 7–8 2024, 12:00-4:00 PM (eastern).

This online class prepares individuals to apply for the Institute for Healthcare Improvement patient safety certification program. The on-demand or live sessions cover key patient safety concepts to enhance participants' knowledge about safety culture, systems thinking, leadership, risk identification and analysis, information technology, and human factors.

The Role of Undergraduate Nursing Education in Patient Safety

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Perspective on Safety November 27, 2023

This piece discusses how undergraduate professional nursing education integrates the topic of patient safety into classroom and clinical instruction, and how this affects patient safety as a whole.

In Conversation with Joan Stanley about The Role of Undergraduate Nursing Education in Patient Safety

Creating Workforce Joy and Wellbeing.

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Institute for Healthcare Improvement. March 6 - May 20, 2024.

Burnout among health care workers negatively affects system improvement. This webinar series will highlight strategies to establish a healthy work environment that strengthens teamwork, staff engagement, and resilience. Instructors include Dr. Donald Berwick and Derek Feeley.

Intravenous (IV) push medications – bridging the gap between education and clinical practice.

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ISMP Medication Safety Alert! Acute Care. November 2, 2023;28(22):1-4.

Intravenous (IV) push medication administration is a primary therapeutic approach where process gaps can result in harm. This article examines existent presence of recognized safe practice education in close to 200 surveyed nursing programs to assess the teaching of standardized practice behaviors at the student level and recommend strategies to embed IV safety into instruction efforts.

Medical students' experiences, perceptions, and management of second victim: an interview study.

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Krogh TB, Mielke-Christensen A, Madsen MD, et al. BMC Med Educ. 2023;23:786.

Medical trainees suffer from "second victim syndrome" (SVS) at rates similar to practicing healthcare professionals but they may not have the same resources to recover. This study of medical students' experiences describes the usual triggers of SVS such as patient harm, but also from negative responses by supervising physicians. Formal instruction and open discussion of SVS can support students' well-being and recovery.

Psychological safety as a new ACGME requirement: a comprehensive all-in-one guide to radiology residency programs.

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Mohamed I, Hom GL, Jiang S, et al. Acad Radiol. 2023;Epub Sep 22.

Psychological safety is an important principle in identifying problems and improving patient outcomes. This narrative review highlights five best practices to foster psychological safety in radiology residencies – (1) establish clear goals and educational strategies, (2) build a formal mentoring program, (3) assess psychological safety, (4) advocate for radiologists as educators, and (5) support non-radiology staff. Although the review focuses on radiology residency programs, these strategies can be adapted to any residency program.

Using in situ simulation to identify latent safety threats in emergency medicine: a systematic review.

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Grace MA, O'Malley R. Simul Healthc. . 2023;Epub Sep 19.

In situ simulation can reveal latent safety threats before they cause harm. This review identified 15 studies of in situ simulations conducted in the emergency department including simulations conducted prior to opening new facilities and to address emerging COVID-19 concerns. The most commonly identified safety threats were related to equipment and team communication.

Supporting nurses in acute and emergency care settings to speak up.

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Clarke-Romain B. Emerg Nurse. 2023;Epub Sep 19.

Delays in raising concerns in acute or emergency care can have tragic consequences. This commentary uses a case study to highlight barriers to speaking up and evidence-based tools nurses can use such as the CUS Tool and two-challenge rule. Training all healthcare staff in communication techniques can encourage speaking up and respectful responses.

Sentinel Event Alert 68: Updated surgical fire prevention for the 21st Century.

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Jt Comm J Qual Patient Saf. 2023;Epub Oct 18.

Surgical fires are a rare yet potentially harmful event for both patients and care teams. The alert provides reduction guidance for organizations to mitigate conditions that enable surgical fires and suggests tactics to improve communication as a primary strategy for preventing this potentially catastrophic accident in operating rooms.

Improving Patient Safety with Human Factors Methods.

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Armstrong Institute for Patient Safety and Quality, Baltimore, MD. April 17-18, 2024.

Human factors engineering (HFE) is a primary strategy for advancing safety in health care. This virtual workshop will introduce HFE methods and discuss how they can be used to reduce risk through design improvements in a variety of process and interpersonal situations.

Redesigning Event Review with RCA2.

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Institute for Healthcare Improvement. March 13 - April 23, 2024.

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.

CUSP Implementation Training.

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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 January 16, 2024.

Diagnostic Safety and Quality Webinar Series: Overview and Implications for Hospitals.

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The Leapfrog Group. November 28, 2023, 3:00--4:00 PM (eastern).

Diagnostic errors in hospitals are the focus on continued improvement efforts as they are common, costly, and harmful. This last in a three-part series of webinars will focus on existing learning strategies to improve diagnosis in hospitals. Dr. Divvy Upadhyay is the featured speaker.

Voices from frontline nurses on care quality and patient safety during COVID-19: an application of the Donabedian Model.

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Pogorzelska-Maziarz M, de Cordova PB, Manning ML, et al. Am J Infect Control. 2023;Epub Aug 23.

The COVID-19 pandemic highlighted systemic weaknesses in the healthcare system. This survey of 3,067 registered nurses working in New Jersey used the Donabedian framework to identify challenges related to providing safe care during the pandemic. Respondents identified several organizational factors, including inadequate resources and staffing, which adversely impacted their ability to adhere to patient safety and infection prevention and control protocols during the pandemic.

Adverse drug event prevention and detection in older emergency department patients.

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Koehl JL. Clin Geriatr Med. 2023;39:635-645.

Older adults are at increased risk of medication errors due to medical complexity and polypharmacy. This article discusses medication safety and adverse drug events specific to a geriatric population and highlights prescribing and deprescribing tools that can contribute to safer prescribing practices.

Defining a high-quality and effective morbidity and mortality conference: a systematic review.

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Beaulieu-Jones BR, Wilson S, Howard DS, et al. JAMA Surg. 2023;Epub Oct 18.

Morbidity and Mortality Conferences (MMC) have a long history in medical education and error analysis. This review summarizes MMC best practices to optimize format and design to advance trainee education and format. Four overarching themes emerged, including formal preparation in advance of the MMC, a balance of presentation and discussion, formal channels for quality improvement and education, and an emphasis on safety culture.

Rethinking Patient Safety: A Discussion Guide for Patients, Healthcare Providers and Leaders.

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Gilbert R, Asselbergs M, Davis D, et al. Healthcare Excellence Canada; 2023.

Patient safety requires a systems approach to identify problems and arrive at lasting solutions that reduce harm. This document encourages discussion amongst a broad base of stakeholders to address all forms of harm, such as discrimination, inequality, and psychological stress, in addition to physical injury. The resource insists these components be incorporated in work to close quality and safety gaps across the health care system.

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