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 310 Results

Understanding And Addressing Pre-Hospital Diagnostic Delays.

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Health Affairs Forefront; May-September 2023.

Diagnostic delays stem from both human and process failures. This series of articles examines how strategies such as behavioral design, internet use, and prehospital practice play a role in the timing of diagnosis.

Deficient Care of a Patient Who Died by Suicide and Facility Leaders' Response at the Charlie Norwood VA Medical Center in Augusta, Georgia.

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Washington DC: Department of Veterans Affairs, Office of Inspector General; May 10, 2023. Report no. 22-01116-110.

… of Veterans Affairs, Office of Inspector General ; May 10, 2023. Report no. 22-01116-110. …

Building a Culture of Safety in Health Care.

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Chicago, IL: American Hospital Association: May 2023.

Healthcare-acquired infections (HAIs) are a common complication of hospital care. This report summarizes lessons learned at a series of infection prevention and control listening sessions. Challenges, opportunities for improvement, and impacts of COVID-19, both positive and negative, are presented.

Medication guides: patient medication information. A proposed rule by the Food and Drug Administration.

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May 31, 2023; Fed Register;88:35694-35728.

Standardized medication labels have been shown to increase patient comprehension and adherence. The Food and Drug Administration (FDA) is proposing a rule which, if approved, would require an easily understandable, one-page medication guide be given to patients when receiving medication in the outpatient setting. Written comments may be submitted through November 27, 2023.

ISMP Survey on the 2022-2023 Targeted Medication Safety Best Practices for Hospitals.

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Institute for Safe Medication Practices. May 2023.

… June 30, 2023. … Institute for Safe Medication Practices. May 2023. … ISMP …

What Happened to Patient Safety.

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Sheridan S. Turn on the Lights. Institute for Healthcare Improvement. May 2023

Patient engagement is an important component in patient safety. This episode from the Turn on the Lights podcast (hosted by Institute for Healthcare Improvement leaders Don Berwick, MD and Kedar Mate, MD) features a discussion with Sue Sheridan from Patients for Patient Safety US about the importance of involving patients and patient perspectives in the development of patient safety solutions.

A national safety board made transportation safer and could do the same for health care, advocates say.

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Jaklevic MC. CNN. May 30, 2023.

Patient safety has long drawn from aviation safety strategies to inform improvement. This article examines the potential for transparency and learning should a National Patient Safety Board be established in the United States. Like the National Transportation Safety Board concept, the proposed agency would collect data on facilities where errors occurred, which is discussed as a barrier to acceptance of the safety board approach in health care.

As cancer drug shortages grow, some doctors are forced to ration doses or delay care.

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Kopf M, Beck C. NBC News. May 26, 2023.

Lack of access to appropriate cancer medications can be particularly difficult for patients and clinicians. This news article discusses the current shortage of chemotherapy drugs, the psychological and physical harm potential in the situation and what should be done to improve medication supply.

Hospitals in two states denied an abortion to a miscarrying patient. Investigators say they broke federal law.

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Surana K. Pro Publica. May 19, 2023.

The unintended clinical consequences of abortion restrictions are beginning to emerge. This article shares how one woman faced personal health risks due to clinician concerns stemming from barriers to abortion care and how the Emergency Medical Treatment & Labor Act (EMTALA) may be employed to minimize care limitations in emergent pregnancy-related situations.

Why do so many Black women die in pregnancy? One reason: doctors don't take them seriously.

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Stafford K. AP News. May 23, 2023.

Racial inequities and implicit bias undermine safe maternal care. This article highlights the potential for maternal sepsis in the Black patient population and the role structural racism plays in this situation. The article is a part of the 2023 “Birth to Death" article series.

Smart infusion pump investigations after an unexplained over-infusion.

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ISMP Patient Safety Alert! Acute care edition. May 18, 2023;28(10);1-3.

Dose error-reduction systems (DERS) and drug libraries are tools for use with smart infusion pumps to ensure safe intravenous medication administration. This article discusses infusion problems unrelated to user error that went undetected by the technology and reached patients. Recommendations to minimize similar occurrences include removing the involved device from service and investigating the incident.

Death Inside Lemuel Shattuck Hospital: A Case Study on Medical Treatment for Persons with Mental Health Disabilities.

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Massachusetts Protection and Advocacy. Boston, MA: Disability Law Center; May 8, 2023.

Behavioral health patients present unique challenges in their care that can contribute to unintended harm. The analysis examines a delayed diagnosis, referral, and treatment of skin cancer that contributed to the death of a patient. Suggestions for improvement included conducting a root cause analysis to identify systemic problems, use of photography to track skin lesion progression, and implementation of a warm handoff process to improve staff communication.

AI may be on its way to your doctor’s office, but it’s not ready to see patients.

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Tahir D. KFF Health News. May 12, 2023.

Real-time use of artificial intelligence (AI) in health care settings continues to cause concern despite its potential to improve care. This article examines current efforts to develop AI applications for health care and the reasons for oversight to protect privacy, reduce bias, and prevent misinformation.

Racial and ethnic disparities in obstetric and gynecologic care and role of implicit biases.

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Bryant A. UpToDate. May 18, 2023.

Implicit bias is progressively being discussed as a detractor to safe health care by fostering racial and ethnic inequities. This review examines the history of health inequities at the patient, provider, health care system, and cultural levels in obstetric and gynecologic care. It shares actions documented in the evidence base for application in health care to reduce the impact of implicit bias, with an eye toward maternal care

How the opioid backlash went wrong.

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Freedman DH. Newsweek Magazine. May 12, 2023.

… supply constraints. … Freedman DH. Newsweek Magazine . May 12, 2023. … David H Freedman, …

Medical errors kill thousands of people each year. But are hospitals getting any safer?

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Weintraub K. USA Today. May 3, 2023.

The semi-annual Leapfrog Hospital Safety Grades are recognized across the industry as a tool for highlighting successes and tracking gaps in safety to focus improvement efforts. This article shares one organization’s work to improve core safety activities related to medication safety, falls, infections, and hand hygiene.

Ensuring competency and safety when onboarding newly hired professional staff.

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ISMP Medication Safety Alert! Acute care edition. April 20, 2023;28(8):1-4; May 4, 2023;23(9):1-3.

Psychological safety is required for clinicians to ask questions as they adjust to working in new teams and environments. Part 1 of this article examines the cultural qualities enabling safe onboarding of new practitioners that encourage asking for assistance when uncertainty arises. Recommendations to encourage new hire questioning include mentor programs and scheduled supervisor conversations. Part 2 discusses the role of simulation to build skills in new staff to ensure medication safety.

The physiology of failure: identifying risk factors for mortality in emergency general surgery patients using a regional health system integrated electronic medical record.

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Baimas-George M, Ross SW, Hetherington T, et al. J Trauma Acute Care Surg. 2022;93:409-417.

Emergency surgery carries an increased risk of death compared to elective surgery. This study used a regional electronic health record (EHR) to examine clinical risk factors associated with mortality in emergency general surgery. Risk factors for both inpatient and 1-year mortality included older age, underweight, neutropenia, and elevated lactate.

Identifying boundary spanning reporter roles in patient safety events.

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Hurley VB, Boxley C, Sloss EA, et al. J Patient Saf Risk Manag. 2022;27:181-187.

Research has shown wide variation in error reporting by profession, with nurses reporting substantially more often than physicians. This study explored not only report rates by profession, but also across departments and event types. Results indicate physicians and technicians are more likely to report errors from across departmental boundaries , while nurses and physicians report a wider variety of error types.

The barriers and enhancers to trust in a just culture in hospital settings: a systematic review.

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van Marum S, Verhoeven D, de Rooy D. J Patient Saf. 2022;18:e1067-e1075.

Underutilization of error reporting systems may be due to a variety of factors, including a culture of fear or blame. This systematic review identified three types of factors influencing trust in error reporting – organizational factors (e.g., management style, focus on safety instead of punitive measures, leadership walk-rounds, established incident reporting systems), team factors (e.g., clearly defined team roles, relationships among teammates), and experience (e.g., knowledge of incident reporting systems, minimizing fear of shame or blame).

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