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
Displaying 1 - 18 of 18 Results
Hoang R, Sampsel K, Willmore A, et al. CJEM. 2021;23:767-771.
The emergency department (ED) is a complex and high-risk environment. In this study, patient deaths occurring within 7 days of ED discharge were analyzed to determine if the deaths were anticipated or unanticipated and/or due to medical error. Rates of unanticipated death due to medical error were low, however clinicians should consider related patient, provider, and system factors.
Thull-Freedman J, Mondoux S, Stang A, et al. CJEM. 2020;22:738-741.
This commentary reviews the principles of high reliability organizations and their application to emergency department pandemic response and describes the experience of one children’s hospital in Alberta, Canada applying these principles in responding to the COVID-19 pandemic. Actions taken by the hospital included the use of an interprofessional ED quality council to identify processes where high reliability is essential in the context of the COVID-19 pandemic, such as resuscitations, intubations, donning and doffing of personal protective equipment (PPE), and preventing contamination.
Plint AC, Stang A, Newton AS, et al. BMJ Qual Saf. 2021;30:216-227.
This article describes emergency department (ED)-related adverse events in pediatric patients presenting to the ED at a pediatric hospital in Canada over a one-year period.  Among 1,319 patients at 3-months follow-up, 33 patients (2.5%) reported an adverse event related to their ED care.  The majority of these events (88%) were preventable. Most of the events involved diagnostic (45.5%) or management issues (51.5%) and resulted in symptoms lasting more than one day (72.7%).
Lobos A-T, Ward N, Farion KJ, et al. Simul Healthc. 2019;14:209-216.
Root cause analysis (RCA) is a vital tool to assess errors and prevent their recurrence. However, many have identified limitations to traditional RCAs. This study found that when RCA was adapted into a simulation format and compared to traditional RCA, simulation participants identified novel sources of error as well as creative solutions.
Lefebvre G, Calder LA, De Gorter R, et al. J Obstet Gynaecol Can. 2019;41:653-659.
Obstetrics is a high-risk practice that concurrently manages the safety of mothers and newborns. This commentary describes the importance of standardization, checklist use, auditing and feedback, peer coaching, and interdisciplinary communication as strategies to reduce risks. The discussion spotlights the need for national guidelines and definitions to reduce variation in auditing and training activities and calls for heightened engagement of health care professionals to improve the safety and quality of obstetric care in Canada. An Annual Perspective reviewed work on improving maternal safety.
Jun S, Plint AC, Campbell SM, et al. Acad Emerg Med. 2018;25:494-507.
This scoping review of cognitive support technology in the emergency department found that physician use of point-of-care support was the most widely studied. Researchers found that few studies measured actual use of cognitive support. The limited data suggest that real-world use of cognitive support delivered via technology remains low.
Stang A, Thomson D, Hartling L, et al. Clin Pediatr (Phila). 2018;57:62-75.
Children are vulnerable to errors in various health care settings. This review identified thematic factors that uniquely affect the safety of pediatric patients such as physiological development and dependency on adults for care. Safety interventions included training programs and monitoring adverse events. Medication errors were the main patient safety concern identified in the literature.
Bhatt M, Johnson DW, Chan J, et al. JAMA Pediatr. 2017;171:957-964.
Procedural sedation is more commonly used among pediatric patients compared to adult patients. In this prospective study across six emergency departments, researchers found that the occurrence of serious adverse events among children receiving sedation varied depending on the type of medication used.
Kwok ESH, Calder LA, Barlow-Krelina E, et al. BMJ Qual Saf. 2017;26:439-448.
Morbidity and mortality conferences are a longstanding patient safety activity. This pre–post study assessed the impact of implementing a structured method to enhance morbidity and mortality rounds. Investigators found that discussion of cognitive biases and systems issues increased following the intervention, and they recommend wider dissemination of their morbidity and mortality rounds model.
Tubman M, Majumdar SR, Lee D, et al. BMJ. 2005;331:274-7.
This qualitative systematic literature review identifies and summarizes evidence for the use of potassium-containing products in hospitals. Results include examination of current recommendations and data that address those consensus-driven guidelines. Discussion shares the limitations of the literature about medication safety practices and calls for greater attention to improving the evidence base behind patient safety practices in general. The authors conclude that inadequate evidence exists to support specific best practices for the proper handling of potassium products.
WebM&M Case July 1, 2003
A physician in the ED mistakenly glues a child's eye shut when attempting to close a facial wound with skin adhesive.