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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 1713 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.
Essex R, Weldon SM, Thompson T, et al. Health Serv Res. 2022;57:1218-1234.
A systematic review in early 2022 revealed healthcare worker strikes may negatively impact patient safety but also result in long-term benefits. This review by the same authors explores the impact of strikes on in-hospital and population mortality. None of the 11 studies examining in-hospital mortality reported a significant difference between mortality during the strike compared to the control period. Similarly, there was no difference in population mortality.
Rosen A, Carter D, Applebaum JR, et al. J Patient Saf. 2022;Epub Aug 5.
The COVID-19 pandemic had wide-ranging impacts on care delivery and patient safety. This study examined the relationship between critical care clinician experiences related to patient safety during the pandemic and COVID-19 caseloads during the pandemic. Findings suggest that as COVID-19 caseloads increased, clinicians were more likely to perceive care as less safe.
Gogalniceanu P, Karydis N, Costan V-V, et al. J Am Coll Surg. 2022;235:612-623.
Safety strategies from high-reliability industries such as aviation and nuclear power are frequently adapted for healthcare. In this study, pilots described crisis preparedness strategies, which surgical safety experts then developed into a framework consisting of six behavioral interventions: anticipate threats, briefing, checklists, drill rehearsal, individual and team empowerment, and debriefing. An earlier study by the authors describes the second phase in managing crisis: crisis recovery.
Auschra C, Asaad E, Sydow J, et al. J Patient Saf. 2022;Epub Aug 5.
Health systems are increasingly aiming to become high-reliability organizations, able to operate for an extended period without serious accidents. This systematic review identified 75 studies reporting on health systems’ interventions to improve reliability, the goals of the interventions, and how achievement of the goals was measured. The six goals of Crossing the Quality Chasm were used to categorize studies. Most studies focused solely or in part on safety; only ten focused solely on one of the other five goals.
Derdowski LA, Mathisen GE. Safety Sci. 2022;157:105948.
Work-related psychosocial factors may increase or decrease the risk of accidents in high-risk industries (e.g., nuclear, mining, healthcare). Using the Job Demands-Resources (JD-R) framework as a starting point, associations between job demands and resources, and between safety behaviors and outcomes were evaluated. Most studies report on the link between psychosocial factors and safety behavior (e.g., job stress or exhaustion can precede negative safety behavior).
M. Violato E. Can J Respir Ther. 2022;58:137-142.
Healthcare trainees and junior clinicians are often reluctant to speak up about safety concerns. This qualitative study found that simulation training to enhance speaking up behaviors had lasting effects among advanced care paramedics and respiratory therapists as they moved from training into practice. Respondents highlighted the importance of experience for speaking up and the benefits of high-impact simulation training.
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.
Pun BT, Jun J, Tan A, et al. Am J Crit Care. 2022;31:443-451.
Team collaboration is an essential part of ensuring patient safety in acute care settings. This survey of care team members (including nurses, physicians, pharmacists, respiratory therapists, and rehabilitation therapists) assessed teamwork and collaboration across 68 intensive care units (ICUs). Teamwork and work environment were rated favorably but care coordination and meaningful recognition were rated least favorably.
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.
Patient Safety Innovation November 16, 2022

While electronic health records, computerized provider order entry, and clinical decision support have increased patient safety, they can also create new challenges such as alert fatigue. One medical center developed and implemented a program to identify and reduce the number of alerts clinicians encounter every day. 

Patient Safety Innovation November 16, 2022

Appropriate follow-up of incidental abnormal radiological findings is an ongoing patient safety challenge. Inadequate follow-up can contribute to missed or delayed diagnosis, potentially resulting in poorer patient outcomes. This study describes implementation of an electronic health record-based referral system for patients with incidental radiologic finding in the emergency room. 

Tubic B, Finizia C, Zainal Kamil A, et al. Nurs Open. 2022;Epub Oct 31.
Interventions to increase patient engagement in safety are receiving increasing attention. In this study, patients were given a safety leaflet containing information about the patient can avoid adverse events during their hospital stay. Participants were overall satisfied about receiving information about their care but noted a lack of communication between healthcare personnel and patients regarding the safety leaflet.
Sutherland A, Jones MD, Howlett M, et al. Drug Saf. 2022;45:881-889.
Intravenous (IV) medication smart pumps can improve medication administration, but usability issues can compromise safety. This article outlines strategic recommendations regarding the implementation of smart pump technology to improve patient safety. Recommendations include standardization of infusion concentrations, improving drug libraries using a human-centered approach, and increasing stakeholder engagement.
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.
Harton L, Skemp L. J Nurs Manag. 2022;Epub Sep 1.
Nurse leaders play an important role in ensuring a robust patient safety culture. Ten nurse leaders at a United States hospital provided their perspectives on how they ensure a culture of safety on their units. Six overarching themes emerged as well as structural and organizational challenges.
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.