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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 1740 Results
Gilmartin HM, Saint S, Ratz D, et al. Infect Control Hosp Epidemiol. 2023;Epub Sep 13.
Burnout has been reported across numerous healthcare settings and disciplines during the COVID-19 pandemic. Among US hospital infection preventionists surveyed in this study, nearly half reported feeling burnt out, but strong leadership support was associated with lower rates of burnout. Leadership support was also associated with psychological safety and a stronger safety climate.
WebM&M Case September 27, 2023

A 42-year-old man with a history of posttraumatic stress disorder (PTSD), alcohol use disorder and anxiety disorder, was seen in the emergency department (ED) after a high-risk suicide attempt by hanging. The patient was agitated and attempted to escape from the ED while on an involuntary psychiatric commitment. The ED staff treated him as a “routine boarder” awaiting an inpatient bed, with insufficiently robust behavioral monitoring.

Gil-Hernández E, Carrillo I, Tumelty M-E, et al. Med Sci Law. 2023;Epub Jun 27.
Patient safety is a global health concern. For this study, representatives from 27 countries reported on rules, laws, and policies in their country related to adverse events and medical errors. As expected, laws varied widely between countries regarding issues such as apology laws, patient compensation schemes, and legal and emotional support for clinicians involved in adverse events.

Amin D, Cosby K. Rockville, MD: Agency for Healthcare Research and Quality; September 2023. Publication No. 23-0040-6-EF.

Psychological safety to report errors stems from a robust safety culture. This issue brief examines how these two concepts intersect to enhance the self-reporting of diagnostic errors to facilitate organizational learning from mistakes.
Jones A, Neal A, Bailey S, et al. BMJ Lead. 2023;Epub Sep 10.
The well-being of healthcare workers is essential to the delivery of high quality, safe care. This article proposes a definition of “avoidable employee harm” (e.g., retaliation for speaking up about safety concerns) and describes how prioritizing organizational safety culture can increase both employee and patient safety.

Irving, TX: American College of Emergency Physicians; 2023.

Error disclosure is difficult yet important for patient and clinician psychological healing. This statement provides guidance to address barriers to emergency physician disclosure of errors that took place in the emergency room. Recommendations for improvement include the development of organizational policies that support error reporting, disclosure procedures, and disclosure communication training.
Meidert U, Dönnges G, Bucher T, et al. Int J Environ Res Public Health. 2023;20:6569.
Biases among healthcare professionals can lead to inequitable care and poor patient outcomes. Based on 81 included studies, the authors of this scoping review concluded that racial bias among physicians and nurses in the United States is well-documented, but noted that research on biases among other health professionals or in other countries is lacking.
El Boghdady M, Ewalds-Kvist BM. Langenbecks Arch Surg. 2023;408:349.
Disruptive behavior in the healthcare setting can result in neglect of patient care, decreased teamwork, and poor safety culture. This study from the UK found that 22% of surgeons were at risk of displaying disruptive behavior in the workplace and that being bullied during surgical training predicted hostility. These results reinforce the need for strong safety culture and a supportive learning environment for trainees.

Fortis B, Bell L. Pro Publica. September 12, 2023.

Sexual abuse of a patient is a never event. This article discusses how criminal behavior remained latent at a large health system due to persistent disregard of patient concerns, which enabled a serial sexual abuser to continue to practice medicine. The harm to the victims and fear of the peers who knew of the situation and were not psychologically safe enough to report it, are discussed.
Amick AE, Schrepel C, Bann M, et al. Acad Med. 2023;98:1076-1082.
Disruptive behaviors, including experiencing or witnessing coworker conflict, can lead to staff burnout and adverse events. In this study, emergency medicine and internal medicine physicians reported on conflicts with other physicians they'd experienced in the workplace. Participants reported feeling demoralized and burnt out after a conflict and brought those feelings to future interactions, priming the situation for additional conflict.
Kane J, Munn L, Kane SF, et al. J Gen Intern Med. 2023;Epub Sept 5.
Clinicians and staff are encouraged to speak up about safety concerns as a part of patient safety culture. This review had two aims: to review the literature on speaking up for patient safety, and to develop a single definition of "speaking up" in healthcare. 294 articles were identified with 51 directly focused on speaking up and the remaining on other aspects such as communication. 11 distinct definitions were identified from which the authors developed a single definition: a healthcare professional identifying a concern that might impact patient safety and using his or her voice to raise the concern to someone with the power to address it.
Brown CE, Snyder CR, Marshall AR, et al. J Gen Intern Med. 2023;Epub Aug 24.
Structural racism continues to perpetuate health disparities. As part of their study on how black patients with serious illness experience racism from providers, researchers conducted interviews with 21 providers to understand ways they address anti-Black racism in their practice. Providers felt unprepared to address racism with their patients, wanted to provide tools for patients to bring up their experiences while also acknowledging the additional burden this would place on Black patients, and thought patient- and provider-facing programs could facilitate discussions. Additionally, despite extensive research on the negative impacts of structural racism on health, participants cited the need for more data.
Seys D, Panella M, Russotto S, et al. BMC Health Serv Res. 2023;23:816.
Clinicians who are involved in a patient safety incident can experience psychological harm. This literature review of 104 studies identified five levels of support that can be provided to healthcare workers after a patient safety incident – (1) prevention, (2) self-care of individuals and/or teams, (3) support by peers and triage, (4) structured professional support, and (5) structured clinical support.
Mohamoud YA, Cassidy E, Fuchs E, et al. MMWR Morb Mortal Wkly Rep. 2023;72:961–967.
Previous research has found that women often experience mistreatment and discrimination during maternity care. This CDC analysis of survey data for 2,402 respondents found that approximately one in five women experienced at least one type of mistreatment during maternity care (i.e., being ignored or refused, being shouted at or scolded, having their physical privacy violated). Nearly 29% of respondents reported experiencing at least one form of discrimination during their maternity care (i.e., age-, weight-, income-, or race/ethnicity-based discrimination).

Geneva, Switzerland; International Council of Nurses: 2023.

Nursing is foundational to safe patient care. This statement outlines recommendations for the nursing community to support the World Health Organization Global Patient Safety Action Plan 2021-2030. Tactics described target, governmental, organizational, and individual actions for improvement.

West S. KFF Health News. August 24, 2023.

The challenge of unsafe maternal care is gaining deserved attention across the system spectrum. This article discusses the preventative nature of many barriers to safe care Black mothers face including lack of health insurance, limited access to prenatal care and disrespect for concerns during care encounters.
McCarthy SE, Hogan C, Jenkins L, et al. BMJ Open Qual. 2023;12:e002270.
Debriefing after significant clinical events helps affected staff develop a shared mental model of what happened, why it happened, and how it can be prevented in the future. This paper describes development of training videos on after action reviews (AAR)s, a type of debriefing. The videos introduce AAR, show a simulated AAR debriefing, offer techniques for handing challenging situations within an AAR, and reflections on the benefits. The videos are available with the online version of the paper.
Mauskar S, Ngo T, Haskell H, et al. J Hosp Med. 2023;18:777-786.
Parents of children with medical complexity can offer unique perspectives on hospital quality and safety. Prior to their child's discharge, parents were surveyed about their child's care, medications, safety, and other concerns experienced during their stay. Parents reported experiencing miscommunication with the providers and providers seemingly not communicating with each other. They also reported inconsistency in care/care plans, unmet expectations, lack of transparency, and a desire for their expertise to be taken seriously.

Moritz J, Coffey J, Buchanan M. BBC News. August 19, 2023.

Whistleblowers can identify the presence of systemic failures, but the organization is responsible for acting on their reported concerns. This article summarizes the range of breakdowns that contributed to a British nurse serial murderer, who, despite warnings from others, continued to harm babies over several years.