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.
Latent factors are known to contribute to system-level failures. This commentary discusses the Mid Staffordshire NHS Foundation Trust inquiry and the Veterans Affairs health system investigation as examples of how executive expectations to meet performance targets and insufficient safety culture led to unintended consequences and system failures.