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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 452 Results

R3 Report. December 20, 2022;38:1-8.

Health care inequities persist despite increasing awareness they negatively affect quality, safety, and patient centeredness. This article shares the Joint Commission strategy for embedding equity improvement into the National Patient Safety Goal initiative to increase focus on equity as a safety priority across all care environments.

Hare R, Tyler ER, Tapia A, et al. Rockville, MD: Agency for Healthcare Research and Quality; January 2023. AHRQ Publication No. 23-0018.

The AHRQ Surveys on Patient Safety Culture™(SOPS®) Nursing Home Survey assesses safety culture and resident safety in nursing homes. This report summarizes survey data from 3,224 staff working in 62 nursing homes. Respondents reported positive perceptions about both resident safety overall and feedback and communication regarding safety incidents. Areas for improvement included sufficient staffing to handle the workload and maintain resident safety.
Edlow JA, Pronovost PJ. JAMA. 2023;Epub Jan 27.
Medical errors should be examined in the context of system failure to generate lasting opportunities for learning and improvement. This commentary discusses the AHRQ 2022 report entitled Diagnostic Errors in the Emergency Department: a Systematic Review and suggests a focus on care delivery processes over individuals, definitions, error rate review, and system design as noteworthy approaches to error reduction.
Hawkins SF, Morse JM. Glob Qual Nurs Res. 2022;9:233339362211317.
Medication administration is a complex set of tasks completed many times per day for hospitalized patients. This study captures the turbulence of nursing work, the nursing environment, and how that impacts patient safety. The results suggest organizations should re-evaluate current attempts at improving medication administration safety and include nurses in identifying new solutions.
Seidelman JL, Mantyh CR, Anderson DJ. JAMA. 2023;329:244-252.
Surgical site infections (SSIs) remain a significant cause of preventable post-operative morbidity and mortality. This narrative review summarizes modifiable and nonmodifiable patient-related factors. It also evaluates modifiable operation-related factors associated with surgical site infections, and highlights six pre-, intra-, and postoperative strategies to reduce surgical site infections, including use of the WHO surgical safety checklist.

ISMP Medication Safety Alert! Acute care edition. January 12, 2023;28(1):1-4.

The patient safety movement has raised awareness of the presence of multiple factors that align to result in patient harm, yet implementing processes to fully examine and change practice from that perspective is challenged. This article discusses this situation and provides recommendations to orient improvement efforts toward deeper investigation methods to identify latent contributors to care failure.
Wells JM, Walker VP. Health Promot Pract. 2023:152483992211451.
Addressing racism in healthcare is a patient safety priority. This article discusses how an active presence by hospital threat management systems (e.g., hospital-employed security, local law enforcement personnel) in pediatric emergency departments (EDs) can help ensure patient safety but also contributes to unsafe care due to racial stereotypes and threat perception among minority patients and caregivers. The authors outline patient-centered strategies at the individual-, intra-organizational-, and extra-organizational levels for responding to disruptive and violent events.
Moon SEJ, Hogden A, Eljiz K. BMJ Open Qual. 2022;11:e002057.
Health systems often implement innovative quality improvement and patient safety initiatives, but the longevity and sustainability of these initiatives remains a challenge. This scoping review explored the factors which enable and hinder sustainability of hospital-wide quality improvement (QI) initiatives. Three overarching themes were identified – the role of (1) people, including the organizational and leadership teams, as well as frontline staff implementing the QI initiatives, (2) processes, such as local and organizational integration and planning for sustainability, and (3) the organizational environment such as resources, infrastructure, and hospital culture.
Bushuven S, Trifunovic-Koenig M, Bentele M, et al. Int J Environ Res Public Health. 2022;19:16016.
Healthcare workers (HCWs) who are involved in serious adverse events may feel traumatized by those events, and many organizations have implemented “second victim” training programs to support their workers. This study sought to understand HCWs’ motivations to attend such trainings and a potential association with overconfidence. Understanding the association may help organizations develop effective training programs and increase motivation to attend them.
Riman KA, Harrison JM, Sloane DM, et al. Nurs Res. 2023;72:20-29.
Operational failures – breakdowns in care processes, such as distractions or situational constraints – can impact healthcare delivery. This cross-sectional analysis using population-based survey data from 11,709 nurses examined the relationship between operational failures, patient satisfaction, nurse-reported quality and safety, and nurse job outcomes. Findings indicate that operational failures negatively impact patient satisfaction, quality and safety, and contribute to poor nurse job outcomes, such as burnout.  

DePeau-Wilson M. MedPage Today. January 13, 2023.

The use of anesthesia in ambulatory settings presents both advantage and risk to patients and clinicians. This article discusses evidence defining these issues. It suggests that improved collaboration with anesthesiologists represents opportunities for nonoperating room anesthesia safety.
Barrett AK, Sandbrink F, Mardian A, et al. J Gen Intern Med. 2022;37:4037-4046.
Opioid medication use is associated with an increased risk of adverse events; however research has shown sudden discontinuation of opioids is also associated with adverse events such as withdrawal and hospitalization. This before and after study evaluated the impact of the VA’s Opioid Safety Initiative (OSI) on characteristics and prescribing practices. Results indicate that length of tapering period increased, and mortality risk decreased following OSI implementation.
Hashemian SM, Triantis K. Safety Sci. 2023;159:106045.
Production pressures can inhibit effective decision-making and threaten patient safety. This systematic review examines the effects of production pressures in sociotechnical systems and discusses the need for future research to develop and implement systems to monitor and control production pressures.
Heesen M, Steuer C, Wiedemeier P, et al. J Patient Saf. 2022;18:e1226-e1230.
Anesthesia medications prepared in the operating room are vulnerable to errors at all stages of medication administration, including preparation and dilution. In this study, anesthesiologists were asked to prepare the mixture of three drugs used for spinal anesthesia for cesarean section. Results show deviation from the expected concentration and variability between providers. The authors recommend all medications be prepared in the hospital pharmacy or purchased pre-mixed from the manufacturer to prevent these errors. 
Pratt BR, Dunford BB, Vogus TJ, et al. Health Care Manage Rev. 2022;48:14-22.
Organizational pressures sometimes lead to redeployment or task reallocation such as shifting infusion tasks from specialty nurse teams to generalist nurses. This survey of nurses in the United States found that infusion task reallocation led to increased job demands and reduced resources, thereby contributing to lower perceived organizational safety.
Skead C, Thompson LH, Kuk H, et al. Crit Care Res Pract. 2022;2022:4815734.
After-hours and weekend admissions to the hospital and intensive care units (ICU) have been linked to poor outcomes. This retrospective analysis compared outcomes among adult patients with daytime versus nighttime ICU admissions at one large Canadian medical center in between 2011 and 2015. Researchers found that overall mortality, but not ICU mortality, was higher among daytime admissions.
Thusini S’thembile, Milenova M, Nahabedian N, et al. BMC Health Serv Res. 2022;22:1492.
Health systems often consider return on investment (ROI) when considering implementation of quality improvement and patient safety interventions (i.e., costs saved by preventing medical errors or improving quality of care). This systematic review explored how ROI concepts have been used in studies assessing large-scale quality improvement programs.

Pharmacy Practice News Special Edition. December 13, 2022: 43-54.

Medication errors continue to occur despite long-standing efforts to reduce them. This article summarizes types of errors submitted to the Institute for Safe Medication Practices reporting program in 2021. The piece discusses the medications involved, recommendations for improvement, and technologies to be employed to minimize error occurrence.
WebM&M Case December 14, 2022

A 65-year-old man with metastatic liver disease presented to the hospital with worsening abdominal pain after a partial hepatectomy and development of a large ventral hernia. Imaging studies revealed perforated diverticulitis. A goals-of-care discussion was led by the palliative care service; the patient and his designated decision-makers chose to pursue non-operative management of diverticulitis.