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AHRQ: Agency for Healthcare Research and Quality
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Patient Safety Network

Promoting Patient Safety.

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AHRQ’s Patient Safety Network (PSNet) features a collection of the latest news and resources on patient safety, innovations and toolkits, opportunities for free CME and trainings. The platform provides powerful searching and browsing capability, as well as the ability for users to customize the site around their interests (My Profile).

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Culture of Safety
Medication Errors/Preventable Adverse Drug Events
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The PSNet Collection

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July 24, 2024 Weekly Issue

PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety.

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Study
Long-term care healthcare-associated infections in 2023: an analysis of 23,970 reports.
Kepner S, Bennett A, Jones RM. Patient Safety. 2024;6.
Preventing healthcare-associated infections continue to be a challenge in long-term care settings. Based on reports submitted by long-term care facilities to the Pennsylvania Patient Safety Reporting System (PA-PSRS), infection rates increased for skin and soft tissue, urinary tract, and respiratory tract infections. This continues the trend seen in the 2022 report.
Study
A human right-based approach to dealing with adverse events in residential care facilities.
McGrane N, Behan L, Keyes LM. Health Hum Rights. 2024;26:115-128.
Many regulatory authorities require notification of adverse events involving vulnerable individuals, such as those in care facilities. In this study, almost 200 statutory notifications from residential care facilities (RCF; e.g., nursing homes, assisted living) were analyzed to ensure residents' human rights (fairness, respect, equality, dignity, and autonomy) were upheld during adverse events. In the...
Study
Partnership as a pathway to diagnostic excellence: the challenges and successes of implementing the Safer Dx Learning Lab.
Sloane J, Singh H, Upadhyay DK, et al. Jt Comm J Qual Patient Saf. 2024;Epub May 31.
Improving the diagnostic process requires multipronged and multidisciplinary approaches to achieve lasting improvements. This qualitative study involving 25 individuals associated with the Safer Dx Learning Lab identified several program successes, such as improved reporting workflow and safety culture fostering psychological safety. Participants also highlighted lessons learned, including leadership buy...

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Training and Education

Update Date: July 10, 2024

WebM&M Case Studies & Spotlight Cases

WebM&M (Morbidity & Mortality Rounds on the Web) features expert analysis of medical errors reported anonymously by our readers. Spotlight Cases include interactive learning modules available for CME. Commentaries are written by patient safety experts and published monthly. Contribute by Submitting a Case anonymously.

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Have you encountered medical errors or patient safety issues?
Have you encountered medical errors or patient safety issues? Submit your case below to help the medical community and to prevent similar errors in the future.

Upcoming Events

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International Meeting/Conference
HSJ Patient Safety Congress.

Health Service Journal. September 16-17, 2024. Manchester Central Convention Complex, Manchester UK.

Improvement Resources
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Innovations

The Patient Safety Innovations Exchange highlights important innovations that can lead to improvements in patient safety.

Toolkit
Toolkits

Toolkits provide practical applications of PSNet research and concepts for front line providers to use in their day to day work.

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Create your own library to save and manage content on any topic of interest. You can start by searching for articles or by creating your library right here.
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