Skip to main content

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.

Search All Content

Search Tips
Filter By Author(s)
Advanced Filtering Mode
Date Ranges
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Additional Filters
Approach to Improving Safety
Safety Target
Displaying 1 - 20 of 71 Results
Bates DW, Levine DM, Salmasian H, et al. New Engl J Med. 2023;388:142-153.
An accurate understanding of the frequency, severity, and preventability of adverse events is required to effectively improve patient safety. This study included review of more than 2,800 inpatient records from 11 American hospitals with nearly one quarter having at least one preventable or not preventable adverse event. Overall, approximately 7% of all admissions included at least one preventable event and 1% had a severity level of serious or higher. An accompanying editorial by Dr. Donald Berwick sees the results of this study as a needed stimulus for leadership to prioritize patient safety anew.
Andraska EA, Phillips AR, Asaadi S, et al. J Surg Educ. 2023;80:102-109.
Patients and clinicians may hold implicit gender biases and rate women clinicians more negatively. In this study, adverse event reports written about residents were reviewed to determine if resident gender was associated with different types and frequency of incident reports. The most comment complaint about men physicians involved a medical error, while the most common complaint type about women included a communication-related event. Additionally, women were more frequently identified by name only, without a title such as “doctor”.
de Loizaga SR, Clarke-Myers K, R Khoury P, et al. J Patient Exp. 2022;9:237437352211026.
Parents have reported the importance of being involved in discussions with clinicians following adverse events involving their children. This study asked parents and physicians about their perspectives on inclusion of parents in morbidity and mortality (M&M) reviews. Similar to earlier studies, parents wished to be involved, while physicians were concerned that parent involvement would draw attention away from the overall purpose (e.g., quality improvement) of M&M conferences.
Galiatsatos P, O'Conor KJ, Wilson C, et al. Health Secur. 2022;20:261-263.
Stressful situations can degrade communication, teamwork and decision making. This commentary describes a program to minimize the potential impact of implicit biases in a crisis. Steps in the process include Pausing to Listen, working to Ally and Collaborate, and seeking to Empower patients and staff members.
Ziemba JB, Berns JS, Huzinec JG, et al. Acad Med. 2021;96:997-1001.
Root cause analysis (RCA) is a common method to investigate adverse events and identify contributing factors. To expand resident understanding of and participation in RCA, the authors developed simulated RCAs that were applicable to a broad set of specialties and included other healthcare professionals whose disciplines were involved in the event (e.g., nurses, pharmacists). After participating in the simulated RCAs, there was an increase in trainees understanding of RCA and intent to report adverse events.
Myers LC, Blumenthal K, Phadke NA, et al. Jt Comm J Qual Patient Saf. 2021;47:54-59.
Learning from adverse events is a core component of patient safety improvement. These authors developed guidance for the use of peer review protected information (such as voluntary event reports and root causes analyses) in safety research. The guidance aims to ensure that data are handled safely and appropriately while supporting scientific discovery.  
Alagha MA, Jaulin F, Yeung W, et al. J Patient Saf. 2021;17:87-89.
This article uses an adapted human factors analysis classification system (HFACS) to describe three levels of failure occurring during the COVID-19 pandemic: organizational factors (e.g., resource management, organizational climate), individuals and their environments (e.g., lack of training in  personal protective equipment (PPE) donning), and supervision factors (such as those caused by staffing shortages).

Durning S, Holmboe E, Graber ML, eds. Diagnosis(Berl). 2020;7(3):151-344.

… . 2020;7(3):151-344. … Olson APJ; Fernandez Branson C; van Merrienboer J; Schuwirth LWT … M. … A. … SJ … D. … E. … … E. … JA … K. … H. … B. … AB … L. … K. … SR … CC … ZA … C. … P. … ML … MA … M. … E. … C. … V. … SW … SV … P. … N. … … … Chopra … Russell … Desai … O'Rourke … Ahuja … Patel … Myers … Zulman … Sateia … Berkenblit … Johnson … Garibaldi … …
Myers LC, Heard L, Mort E. Am J Crit Care. 2020;29:174-181.
This study reviewed medical malpractice claims data between 2007 and 2016 to describe the types of patient safety events involving critical care nurses. Decubitus ulcers were the most common diagnosis in claims involving ICU nurses and compared to nurses in emergency departments and operating rooms, ICU nurses were likely to have a malpractice claim alleging failure to monitor.
Gartland RM, Myers LC, Iorgulescu JB, et al. J Patient Saf. 2020;17:576-582.
This study reviewed medical malpractice claims spanning a 10-year period involving deaths related to inpatient care. Two physicians completed a blinded review of the claim to determine whether there was major, minor or no discordance between the final clinical diagnoses and the pathological diagnoses ascertained at autopsy. The researchers found that 31% of claims demonstrated major discordance between autopsy and clinical findings. The most common diagnoses newly discovered on autopsy were infection or sepsis, pulmonary or air embolus, and coronary atherosclerosis. In addition, the researchers found that performing an autopsy was not associated with either the likelihood of payout on a malpractice or the median size of that payout. They conclude that physicians should not hesitate to advocate for autopsies to investigate unexpected in-hospital deaths.
Myers JS, Lane-Fall MB, Perfetti AR, et al. BMJ Qual Saf. 2020;29:645-654.
This study used a mixed-methods approach to characterize the impact of two academic fellowships in Quality Improvement Patient Safety (QIPS) to both graduates and their respective institutions. Students in these programs reported a positive impact of the fellowship on their careers, with nearly all being involved in QIPS administration, research or education upon graduation. Interviewed mentors also generally thought the fellowships were important and the resulting research had departmental, institutional and even national importance.
Rozenblum R, Rodriguez-Monguio R, Volk LA, et al. Jt Comm J Qual Patient Saf. 2019;46:3-10.
Clinical decision support (CDS) tools help identify and reduce medication errors but are limited by the rules and types of errors programmed into their alerting logic and their high alerting rates and false positives, which can contribute to alert fatigue. This retrospective study evaluates the clinical validity and value of using a machine learning system (MedAware) for CDS as compared to an existing CDS system. Chart-reviewed MedAware alerts were accurate (92%) and clinically valid (79.7%). Overall, 68.2% of MedAware alerts would not have been generated by the CDS tool and estimated cost savings associated with the adverse events potentially prevented via MedAware alerts were substantial ($60/drug alert).
Garabedian PM, Wright A, Newbury I, et al. JAMA Netw Open. 2019;2:e191514.
This simulation study compared computerized medication order entry between two commercial electronic health records and a prototype designed for safe prescribing. Physicians using the prototype had fewer errors compared to either commercial platform, highlighting the need to improve electronic health record usability in order to enhance medication safety.
Sellers MM, Berger I, Myers JS, et al. J Surg Educ. 2018;75:e168-e177.
This qualitative study examined incident reports about surgical patients, comparing trainee reports to those submitted by attending surgeons and nurses. Trainees were more likely to enter reports anonymously and completed more elements for each report, but they also used more blame language and submitted fewer reports overall. The results suggest that encouraging trainee reporting may shed light on surgical safety.
Myers JS, Bellini LM. Acad Med. 2018;93:1321-1325.
Although patient safety competency development is increasingly a goal of graduate medical education, skills to teach them are lacking. This project report describes the development, implementation, and outcomes of a curriculum developed to meet quality improvement and patient safety educational requirements. The approach included activities such as event reporting, root cause analysis, and disclosure simulation.
Schiff G, Martin SA, Eidelman DH, et al. Ann Intern Med. 2018;169:643-645.
Safe diagnosis is a complex challenge that requires multidisciplinary approaches to achieve lasting improvement. The authors worked with a multidisciplinary panel to build a 10-element framework outlining steps that support conservative diagnosis. Recommendation highlights include a renewed focus on history-taking and physician examination, as discussed in a PSNet perspective. They also emphasize the importance of continuity between clinicians and patients to build trust and foster timely diagnosis. Taken together with recommendations for enhanced communication between specialist and generalist clinicians and more judicious use of diagnostic testing, this report is a comprehensive approach to reducing overdiagnosis and overtreatment.