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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 3709 Results

Washington State Hospital Association. December 8, 2022, 4:00-5:00 PM (eastern).

Diagnostic error reduction is increasingly embraced as an element of patient safety strategic planning. This session will discuss the role of collaboratives as an approach to improvement and highlight opportunities for improving diagnosis on an organizational level.
Carmack A, Valleru J, Randall KH, et al. Jt Comm J Qual Patient Saf. 2022;Epub Sep 30.
Retained surgical items (RSI) are a never event, a serious and preventable event. After experiencing a high rate of RSIs, this United States health system implemented a bundle to reduce RSI, improve near-miss reporting, and increase process reliability in operating rooms. The bundle consisted of five elements: surgical stop, surgical debrief, visual counters, imaging, and reporting.
Wilson M-A, Sinno M, Hacker Teper M, et al. J Patient Saf. 2022;18:680-685.
Achieving zero preventable harm is an ongoing goal for health systems. In this study, researchers developed a five-part strategy to achieve high-reliability and eliminate preventable harm at one regional health system in Canada – (1) engage leadership, (2) develop an organization-specific patient safety framework, (3) monitor specific quality aims (e.g., high-risk, high-cost areas), (4) standardize the incident review process, including the use of root cause analysis, and (5) communicate progress to staff in real-time via electronic dashboards. One-year post-implementation, researchers observed an increase in patient safety incident reporting and improvements in safety culture, as well as decreases in adverse events such as falls, pressure injuries and healthcare-acquired infections.

Kirkup B. Department of Health and Social Care. London, England: Crown Copyright; 2022.  ISBN: 9781528636759.

Maternity care is beset with challenges that reduce safety. This analysis provided insights into improving maternity care in the British National Health Service (NHS) focusing on the need for identification of inadequate performance, enhanced sympathetic care, common purpose in teams, honest response to difficulties and effective outcome measurement.

Washington, DC: Veterans Affairs Office of Inspector General; 2022. Report No. 22-00818-03.

Organizational evaluations often reveal opportunities to address persistent quality and safety issues. This extensive inspection report shares findings from examinations at 45 Veterans Health Administration care facilities that focused on assessing oversight, system redesign and surgical programs. Recommendations drawn from the analysis call for improvements in protected peer review, surgical work structure and surgical adverse incident examination.
Ünal A, Seren Intepeler Ş. J Patient Saf. 2022;18:e1102-e1108.
Increasing patient safety event reporting is an ongoing priority. This article summarizes the trends in medical error reporting and reporting system research from 1970 to 2021. While the number of publications increased annually, researchers observed a lack of cross-country collaboration on studies evaluating error reporting systems.
McCain N, Ferguson T, Barry Hultquist T, et al. J Nurs Care Qual. 2022;Epub Aug 19.
Daily huddles can improve team communication and awareness of safety incidents. This single-site study found that implementation of daily interdisciplinary huddles increased reporting of near-miss events and improved team satisfaction and perceived team communication, collaboration, and psychological safety.
Adamson HK, Foster B, Clarke R, et al. J Patient Saf. 2022;18:e1096-e1101.
Computed tomography (CT) scans are important diagnostic tools but can present serious dangers from overexposure to radiation. Researchers reviewed 133 radiation incidents reported to one NHS trust from 2015-2018. Reported events included radiation incidents, near-miss incidents, and repeat scans. Most events were investigated using a systems approach, and staff were encouraged to report all types of incidents, including near misses, to foster a culture of safety and enable learning.
Premier House, 60 Caversham Road, Reading, RG1 7EB.
Independent investigations examine system weaknesses in health care to inform improvement, reduce risk, and prevent harm. This organization collects information from individuals, groups, and organizations to identify and analyze incidents of substandard care and to proactively provide recommendations to reduce conditions that perpetuate failure in the National Health Service. Investigation areas include medication delivery for older patients and safe maternity care.
Leapfrog Group. Grand Hyatt, Washington, DC; December 6, 2022.
The Leapfrog Group works with hospitals to survey their progress in adopting patient safety practices. This annual meeting is focused on the theme " Right Now: The Urgency of Patient Safety" to motivate engagement in a wide range of stakeholders and generate needed action in the field. It will host preconference sessions on survey tactics, data and exemplars in the Leapfrog program. 
Groves PS, Bunch JL, Hanrahan KM, et al. Clin Nurs Res. 2022;Epub Oct 17.
Patients can provide a unique perspective on safety concerns but may hesitate to speak up. This study was conducted with 19 recently discharged patients or their family members to understand safety or quality concerns they experienced during their stay and whether they voiced the concern to their care team. The paper presents types of concerns and, if parents did not have concerns, what made them feel safe, as well as barriers and facilitators to speaking up.
Volpini ME, Lekx‐Toniolo K, Mahon R, et al. J Appl Clin Med Phys. 2022;Epub Aug 6.
The COVID-19 pandemic dramatically impacted the way that health care teams function. This study examined how COVID-19-related workflow changes affected reporting of medical errors and near misses occurring in one hospital’s radiation oncology program. After the onset of the COVID-19 pandemic, there was fewer incidents reported overall, but an increase in submissions related to poor documentation and communication.
Newcastle Upon Tyne, UK: Care Quality Commission; October 2022.
This website provides access to an annual report that summarizes National Health Service hospital and social care performance across a range of care quality metrics at both the trust and service level. The 2022 report found most facilities to be generally operating at a effective level and basic performance was found to be high. However the report found substantial gaps in specialties such as maternity care and recognized staffing challenges that impact access and quality.
Charles MA, Yackel EE, Mills PD, et al. J Patient Saf. 2022;18:686-691.
The first surge of the COVID-19 pandemic forced healthcare organizations to respond to patient safety issues in real-time. The Veterans Health Administration’s National Center for Patient Safety established two working groups to rapidly monitor quality and safety issues and make timely recommendations to staff. The formation, activities, and primary themes of safety issues are described.
Kanter MH, Ghobadi A, Lurvey LD, et al. Diagnosis (Berl). 2022;9:430-436.
Diagnostic errors are an emerging area of patient safety research; as such, innovative methods to identify and prevent diagnostic errors are being developed. This commentary describes the development, implementation, and sustainment of a novel method of investigation. The e-Autopsy/e-Biopsy method includes dedicated patient safety staff and volunteer clinical specialists to review events and identify trends. The process is illustrated with three diagnoses: ectopic pregnancy, abdominal aortic aneurysms, and advanced colon cancer.
Barrow E, Lear RA, Morbi A, et al. BMJ Qual Saf. 2022;Epub Oct 5.
Patient and family engagement in safety is a priority for the UK’s National Health Service. This study asked patients in three hospital wards (geriatrics, elective surgery, maternity) how they conceptualize patient safety. Responses described what made them “feel safe” in their experiences with the organization, staff, the patients themselves, and family/carers.

Farnborough, UK: Healthcare Safety Investigation Branch; 2022.

Distinct individual skills and organizational factors strengthen patient safety incident analysis efforts. This series of educational video modules encapsulates a curriculum for investigation teams associated with a national United Kingdom program. It covers topics such as safety science and analysis initiative strategy.

Rockville, MD: Agency for Healthcare Research and Quality. November 7, 2022.

An organization’s understanding of its culture is foundational to patient safety. This webinar introduced the AHRQ Surveys on Patient Safety Culture™ (SOPS®) program. The session covered the types of surveys available and review resources available to best use the data to facilitate conversations and comparisons to inform improvement efforts. 
Adapa K, Ivester T, Shea CM, et al. Jt Comm J Qual Patient Saf. 2022;48:642-652.
Tiered huddle systems (THS) include staff at all levels of the organization- frontline healthcare workers, managers, directors, and executives- and have been shown to increase adverse event reporting and improve safety culture. This US health system implemented a three-level THS in hospital and ambulatory settings to increase event reporting. Based on an interrupted time series analysis, reporting increased for total safety events, including near misses.
Reader TW. J Risk Res. 2022;25:807-824.
Feedback from patients and other stakeholders can illuminate serious patient safety concerns. This qualitative study analyzed stakeholder feedback about patient safety risks as well as how organizations responded to stakeholder communication and discusses ways in which organizational risk management teams can leverage stakeholder feedback. Findings suggest that stakeholder communications have typically focused on safety issues such as medication errors, but that poor safety culture meant that concerns were often not acted upon.