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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 123 Results
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.

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.”
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.
McCord JL, Lippincott CR, Abreu E, et al. Dimens Crit Care Nurs. 2022;41:347-356.
Workarounds can pose significant risks to patient safety. This systematic review including 13 studies found that nursing workarounds most often occurred due to challenges in using the electronic health record (EHR) system or during medication administration.

Washington, DC: VA Office of the Inspector General; September 15, 2022. Report no. 22-00815-232.

Care coordination failures reduce the effectiveness of communication, information transfer, and patient monitoring to the determent of safety. This report examines the current state of interfacility transfers in 45 veteran facilities to find that, while process requirements were basically met, improvements could be made to medication list transfer, nursing communication, and general service evaluation.

President’s Council of Advisors on Science and Technology. Washington, DC: White House; September 21, 2022.

National efforts are required to adjust the health care system and embed safety in programs and processes. Speakers participating in this webinar discussed the impact of errors on families, adverse event prevalence, aviation safety lessons, nursing’s improvement role, the current state of patient safety and what needs to be done to reduce the impact and associated cost of harm.

Tran AK, Calabrese M, Quatrara B, et al. Rockville, MD: Agency for Healthcare Research and Quality; September 2022. AHRQ Publication No. 22-0026-4-EF.

Nurses are underutilized as members of the diagnostic team. This publication examines the role of nursing educators and leaders to enhance the participation of nurses in diagnostic processes. It shares strategies for improving diagnosis through nurse engagement in the process. This issue brief is part of a series on diagnostic safety.

Safer Care for All. London, England:  Professional Standards Authority for Health and Social Care; 2022.

Dedicated leadership is an important component to examine and address challenges to safety across a system. This report outlines a process to reduce the complexity of care across the United Kingdom through the establishment of offices to address inequity, emerging risk regulation, workforce issues, accountability, and lack of trust in the system.

Rockville, MD: Substance Abuse and Mental Health Services Administration; 2022.  SAMHSA Publication No. PEP22-06-02-005.

Behavioral health workers are particularly susceptible to burnout, which sets the stage for unsafe care. This guide highlights organizational strategies to amend six thematic conditions in the behavioral health setting that degrade worker wellbeing: workload; control; reward, promotion, and career development; community; fairness; and values.
Dumitrescu I, Casteels M, De Vliegher K, et al. J Patient Saf. 2022;18:435-443.
Medication errors and other adverse events are thought to occur in 10% of home care patients. This Delphi study identified 27 high-risk medications (e.g., oral chemotherapy, anticoagulants) in home care nursing that require a specific procedure and an additional 28 that warrant additional monitoring. Home care agencies and researchers should focus on developing and evaluating policies to improve safety of high-risk medications.
Linzer M, Sullivan EE, Olson APJ, et al. Diagnosis (Berl). 2022;Epub Aug 22.
Challenging working conditions and increased cognitive workload can result in stress and burnout. This article describes a conceptual framework in which working conditions and cognitive workload impact stress and burnout, which, in turn, impacts diagnostic accuracy. Potential uses and testing of the framework are described.
Stayt LC, Merriman C, Bench S, et al. J Adv Nurs. 2022;78:3371-3384.
The COVID-19 pandemic dramatically changed healthcare delivery across all settings. This qualitative study explored perceptions of patient safety in intensive care among nurses redeployed to intensive care settings during the pandemic. Nurses reported increases in patient safety risks during the pandemic, which were largely attributed to changes in nursing skill mix and poor continuity of care.

ISMP Medication Safety Alert! Acute care edition! August 25, 2022:27(17)1-6.

Unanticipated health information system downtime can occur for technical or malicious reasons and healthcare organizations should be prepared for such disruptive events. This article highlights training, planning, simulation, and leadership support as key elements in the successful response to unplanned information system events to manage staff stress and patient safety.
McKay C, Schenkat D, Murphy K, et al. Hosp Pharm. 2022;Epub Jun 4.
Insulin is a high-alert medication due to heightened risk for serious patient harm if administered incorrectly. This review presents types of common errors (e.g., wrong patient, cross-contamination), pros and cons of potential dispensing strategies, and the impact of organizational factors (e.g., workflows, cost) on safe dispensing. Additionally, the authors make recommendations for dispensing, taking organization factors into account.
Moody A, Chacin B, Chang C. Curr Opin Anaesthesiol. 2022;35:465-471.
Hospital-acquired pressure injuries are considered a never event. This review presents strategies to prevent pressure injuries in the nonoperating room anesthesia (NORA) population (e.g., patients on ventilators). Proper positioning of the patient, with bolsters and padding, are illustrated.
Patrician PA, Bakerjian D, Billings R, et al. Nurs Outlook. 2022;70:639-650.
Clinician well-being has important implications for patient safety and quality of healthcare delivery. In this study, researchers used a concept analysis to identify attributes of nurse well-being at the individual level (e.g., satisfaction, compassion) and organizational/community level (e.g., teamwork, pride in work). These findings can support the development of a standardized definition of nurse well-being to guide future research and policy considerations around well-being and burnout.
van Marum S, Verhoeven D, de Rooy D. J Patient Saf. 2022;18:e1067-e1075.
Underutilization of error reporting systems may be due to a variety of factors, including a culture of fear or blame. This systematic review identified three types of factors influencing trust in error reporting – organizational factors (e.g., management style, focus on safety instead of punitive measures, leadership walk-rounds, established incident reporting systems), team factors (e.g., clearly defined team roles, relationships among teammates), and experience (e.g., knowledge of incident reporting systems, minimizing fear of shame or blame).