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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 1376 Results
Temkin-Greener H, Mao Y, McGarry B, et al. J Am Med Dir Assoc. 2022;Epub Oct 18.
Long-term care facilities can struggle with establishing a safety culture. Researchers in this study used a national survey on nursing home safety culture to assess patient safety culture in assisted living facilities. Findings show that direct care workers had significantly worse perceptions of patient safety culture (including nonpunitive responses to mistakes, management support for resident safety, and teamwork) compared to administrators. A PSNet perspective discusses how to change safety culture.
Ostrovsky D, Novack V, Smulowitz PB, et al. JAMA Network Open. 2022;5:e2241461.
Previous research has found that fear of malpractice can influence medical decision-making. This survey of emergency department attending physicians and advanced practice clinicians in Massachusetts found that fear of harming patients played a larger role in medical decision-making than fear of legal action.

Baker MB. Harv Civ Rights-Civil Lib Law Rev. 2022: 57(Summer):321-360.

Women of color are at risk of bias that reduces the safety of their medical care experience. This article discusses the history of racism in health care, low quality maternal care of Black women, and barriers to safe care for that patient population. The piece also discusses challenges to effective legal response for Black women who experience poor care and strategies to address those barriers.

Jean-Pierre P. Boston U Law Rev. 2022; 102(1):327-392.

Bias and discrimination are receiving overdue attention as primary barriers to patient safety. This article discusses medical error, ineffective response to error, social trust and health care, state apology laws and the role of communication and resolution programs (CRP) to reduce additional harms associated with medical errors, all in the context of marginalized populations.
Sephien A, Reljic T, Jordan J, et al. Med Educ. 2022;Epub Oct 1.
The Accreditation Council for Graduate Medical Education (ACGME) includes work hour restrictions in its Common Program Requirements. The focus of this review is the impact of resident work hour restrictions on patient- and resident-level outcomes. Shorter shift hours were associated with some improved resident outcomes and but no association with patient outcomes.
Ibrahim M, Szeto WY, Gutsche J, et al. Ann Thorac Surg. 2022;114:626-635.
Reports of poor care in the media or public reporting systems can serve as an impetus to overhauling hospitals or hospital units. After several unexpected deaths and a drop in several rating systems, this cardiac surgery department launched a comprehensive quality improvement review. This paper describes the major changes made in the department, including role clarity and minimizing variation in 24/7 staffing.
Chokshi DA, Beckman AL. JAMA Health Forum. 2022;3:e224703.
Never events serve as triggers to motivate substantive improvement in health care organizations should they occur. This commentary expands the concept to include organizational policies that harm patients and reduce care quality. The authors highlight five strategies to be considered as never events that are particularly problematic for patients: debt collection, inadequate community support, lack of cost transparency, poor staff salaries, and racially-segregated care provision.

Rockville, MD: Agency for Healthcare Research and Quality; October 2022.

Diagnostic improvement engages a variety of activities to achieve excellence. This announcement highlights ten organizations AHRQ funded to establish Diagnostic Safety Centers of Excellence. Their focused efforts will work to improve diagnostic safety and quality. Areas of project focus include use of information technology to improve diagnostic accuracy and teamwork as an improvement strategy.

Kaplan A. NBC News. October 27, 2022. 

Suboptimal working conditions are a known contributor to errors in retail pharmacies. This news article discusses how one major pharmacy chain will adjust their staff quality metrics to eliminate timing as a performance measure in the interest of reducing pharmacist and staff burnout and fulfilment errors.

Rau J.  Kaiser Health News. November 1, 2022.

The COVID-19 pandemic necessitated adjustments in activities across health care to address patient care and staffing demands. This news article discusses COVID-19’s impact on the hospital-acquired condition reduction program, and how 43 percent of US hospitals failed to reach readmission goals.
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. 
Trout KE, Chen L-W, Wilson FA, et al. Int J Environ Res Public Health. 2022;19:12525.
Electronic health record (EHR) implementation can contribute to safe care. This study examined the impact of EHR meaningful use performance thresholds on patient safety events. Researchers found that neither full EHR implementation nor achieving meaningful use thresholds were associated with a composite patient safety score, suggesting that hospitals may need to explore ways to better leverage EHRs and as well other strategies to improve patient safety, such as process improvement and staff training.

US Department of Health and Human Services.

The large system change required to reduce patient harm requires multi-stakeholder engagement and sustained commitment. This alliance will work with healthcare systems, federal partners, patients and families, and other stakeholders to implement a national plan to ensure the safety of patients and healthcare workers. The webinar introducing the program, featuring Department of Health and Human Services Secretary Xavier Becerra, was held November 14, 2022.
Dehmoobad Sharifabadi A, Clarkin C, Doja A. BMJ Open. 2022;12:e063104.
Several countries have resident duty hour (RDH) restrictions and there are numerous publications examining the impact of RDH on patient safety. This study used two online discussion forums (one primarily in the United States and the other in Canada) to assess resident perceptions of RDH. Themes included its impact on residents’ education and clinician well-being, and, worryingly, discussions of not reporting RDH violations.
Boamah SA, Hamadi HY, Spaulding AC. J Patient Saf. 2022;18:e1090-e1095.
Medicare’s Hospital-Acquired Condition (HAC) Reduction Program financially incentivizes hospitals to reduce HAC rates and earlier research has shown hospitals in more diverse areas have higher odds of performing poorly. This study compares HAC reduction in Magnet and non-Magnet hospitals and examines potential racial and ethnic disparities. Similar to an earlier study, Magnet hospitals had significant improvements in methicillin-resistant Staphylococcus aureus (MRSA) rates, but not other HACs.
Sachs JD, Karim SSA, Aknin L, et al. Lancet. 2022;400:1224-1280.
COVID-19 illuminated gaps in emergency preparedness and healthcare delivery in the face of a global pandemic. This report from the Lancet Commission identifies strategies for strengthening the multilateral system to address global emergencies such as the COVID-19 pandemic. The report describes a conceptual framework for understanding pandemics; reviews global, regional, and national responses to the COVID-19 pandemic; and provides recommendations for ending the COVID-19 pandemic and preparing for future pandemics.
Windish DM, Catalanotti JS, Zaas A, et al. J Gen Intern Med. 2022;37:2650-2660.
In 2022, the Accreditation Council on Graduate Medical Education (ACGME) began requiring residency programs to provide instruction and experience in pain management for internal medicine trainees. Residency program directors were surveyed in 2019 about whether and how they provide instruction and experience to residents in safe opioid prescribing (SOP) and treatment of opioid use disorder (OUD). Most programs required didactic learning, but few required clinical experience. Given that the ACGME requirement is now in place, the researchers suggest many programs may be ill-prepared to meet the requirement.

Washington, DC: United States Government Accountability Office; Publication GAO-22-105133. September 14, 2022.

COVID-19 generated unprecedented challenges for the nursing home industry, revealing and amplifying process, staffing, trust, and infection control weaknesses to the detriment of care. This report analyzed current infection protection actions in long-term care. A primary improvement conclusion drawn from the examination is to strengthen the role of infection control professionals.

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.