U.S. flag

An official website of the Department of Health & Human Services

AHRQ: Agency for Healthcare Research and Quality
Provide Feedback |
Submit a Case
Patient Safety Network

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

Advanced Search Search by Author
Search Tips
Save
Download citations
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Narrow Results By
Search By Author(s)
PSNet Original Content
Commonly Searched Resource Types
Additional Filters
All Resource Types
Approach to Improving Safety
Clinical Area
Error Types
Safety Target
Setting of Care
Target Audience
Origin/Sponsor
Displaying 1 - 20 of 134 Results
  • 20
  • 50
  • 100
    • Potentially inappropriate medication use is associated with increased risk of incident disability in healthy older adults.
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • Lockery JE, Collyer TA, Woods RL, et al. J Am Geriatr Soc. 2023;71:2495-2505.
    Potentially inappropriate medications (PIM) are a known contributor to patient harm in older adults. In contrast to most studies of PIM in patients with comorbid conditions or residing in hospitals or nursing homes, this study evaluated the impact of PIM use in community-dwelling older adults without significant disability. Participants with at least one PIM were at increased risk of physical disability and hospitalization over the study period (8 years) than those not taking any PIM. However, both groups had similar rates of death.
    A national analysis of ED presentations for early pregnancy and complications: implications for post-Roe America.
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • Goodwin G, Marra E, Ramdin C, et al. Am J Emerg Med. 2023;70:90-95.
    When the US Supreme Court overturned Roe v. Wade, access to safe reproductive care was restricted even for patients with wanted or non-viable pregnancies. This study describes trends in early pregnancy-related emergency department visits prior to the court decision and how new restrictions have resulted in physician uncertainty and delays in care in states with abortion bans. The authors recommend physicians be mindful of Emergency Medical Treatment and Active Labor Act (EMTALA) when caring for pregnant individuals in the emergency department.
    Evaluation of detected medication errors within the operating room at an academic medical center.
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • Wolf M, Rolf J, Nelson D, et al. Hosp Pharm. 2023;58:309-314.
    Medication administration is a complex process and is a common source of preventable patient harm. This retrospective chart review of 145 surgical patients over a two-month period found that 98.6% of cases involved a potential medication error, most frequently due to potential dose omissions and involving vasopressors, opioids, or neuromuscular blockers.
    2022 Updated Results for the AHRQ Surveys on Patient Safety Culture Workplace Safety Supplemental Item Set for Hospitals.
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL

    • Hare R, Tyler ER, Tapia A, Fan L, et al. Rockville, MD: Agency for Healthcare Research and Quality; November 2022. AHRQ Publication No. 22(23)-0008.

    The AHRQ Surveys on Patient Safety Culture™ (SOPS®) Hospital Survey Hospital Survey on Patient Safety Culture ask health care providers and staff about the extent to which their organizational culture supports patient safety. The SOPS Workplace Safety Supplemental Item Set for Hospitals was designed for use in conjunction with the AHRQ Hospital Survey to help hospitals assess the extent to which their organization’s culture supports workplace safety for providers and staff. This data analysis found “Protection From Workplace Hazards” as the highest-scoring composite measure and “Addressing Workplace Aggression From Patients or Visitors” as the lowest-scoring composite measure. An average of 34% of healthcare providers and staff experienced symptoms of “Work Stress/Burnout” which represents a 4-percentage point increase from the 2021 pilot study results.
    Optimizing Pediatric Patient Safety in the Emergency Care Setting.
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • Joseph MM, Mahajan P, Snow SK, et al. Pediatrics. 2022;150:e2022059673.
    Children with emergent care needs are often cared for in complex situations that can diminish safety. This joint policy statement updates preceding recommendations to enhance the safety of care to children presenting at the emergency department. It expands on the application of topics within a high-reliability framework focusing on leadership, managerial factors, and organizational factors that support safety culture and workforce empowerment to support safe emergency care for children.
    Effect of a rapid response team on the incidence of in-hospital mortality.
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • Factora F, Maheshwari K, Khanna S, et al. Anesth Analg. 2022;135:595-604.
    Rapid response teams (RRT) are designed to intervene at the earliest signs of clinical deterioration to prevent intensive care unit transfer, cardiac arrest, or death. This study presents the changes of in-hospital mortality rates following implementation of RRT, introduction of anesthesiologist-led RRT, and other policy changes. Results indicate a gradual decline of in-hospital mortality in the nine-year period following RRT introduction.
    Communication disparities between nursing home team members.
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • Farrell TW, Butler JM, Towsley GL, et al. Int J Environ Res Public Health. 2022;19:5975.
    A robust culture of safety encourages open communication between team members. Certified nursing assistants (CNAs) and nurses in nursing homes were asked about the extent to which their input about residents was valued by the other team members. CNAs reported they felt valued by other CNAs and nurses, but less valued by physicians and pharmacists.
    2022 Updated Results for the AHRQ Surveys on Patient Safety Culture (SOPS) Diagnostic Safety Supplemental Items.
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL

    • Famolaro T, Hare R, Tapia A, et al. Rockville, MD: Agency for Healthcare Research and Quality; April 2022. AHRQ Publication No. 22-0027.

    … of discussions about misdiagnoses when they occurred. … Famolaro T, Hare R, Tapia A, et al. Rockville, MD: Agency for … No. 22-0027. … Fan L, Ji S, Yount ND, Gray L, Zebrak K, Sorra J …
    Surveys on Patient Safety Culture (SOPS) Medical Office Survey: 2022 User Database Report.
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL

    • Famolaro T, Hare R, Tapia A, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2022. AHRQ Publication No. 22-0017.

    The AHRQ Medical Office Survey on Patient Safety Culture  is designed to assess safety culture in outpatient clinics. The 2022 comparative data report includes data from 1,100 US medical offices and over 13,000 providers and staff. The highest-scoring composite measures are patient care tracking/follow-up and teamwork. Like the 2020 report, the lowest-scoring measure was work pressure and pace.
    Surveys on Patient Safety Culture™ (SOPS®) Ambulatory Surgery Center Survey: 2021 User Database Report.
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL

    • Famolaro T, Hare R, Tapia A, Yount et al. Rockville, MD: Agency for Healthcare Research and Quality; December 2021. AHRQ Publication No. 22-0004.

    … as committed to learning and continuous improvement. … Famolaro T, Hare R, Tapia A, Yount et al. Rockville, MD: Agency for … Famolaro T, Hare R, Tapia A, Yount ND, Fan L, Liu H, Sorra J …
    Deprescribing as a Patient Safety Strategy
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL
    • Patient Safety Primer October 27, 2021

    Deprescribing is an intervention used to reduce the risk of adverse drug events (ADEs) that can result from polypharmacy. It is the process of supervised medication discontinuation or dose reduction to reduce potentially inappropriate medication (PIM) use.

    Medical Office Survey: 2020 User Database Report.
    Save to Library
  • Facebook
  • Twitter
  • Linkedin
  • Copy URL

    • Famolaro T, Hare R, Thornton S, et al. Surveys on Patient Safety CultureTM (SOPSTM). Rockville, MD: Agency for Healthcare Research and Quality; March 2020. AHRQ Publication No. 20-0034.

    A vibrant culture of safety is critical to achieving high reliability in health care. Ambulatory practices with weaker safety cultures can experience problems in teamwork, diagnosis, and staff turnover. The AHRQ Medical Office Survey on Patient Safety Culture was designed to evaluate safety culture in outpatient clinics. The 2020 comparative database report assessed 10 safety culture domains in 1,475 medical offices. Respondents reported effective patient follow-up practices and scored well on equitable care delivery. Many practices cited time pressure and workload as persistent challenges to safety hazards. Although the practices surveyed are not nationally representative, they do provide a comparative safety culture snapshot for industry assessment. A past WebM&M commentary discussed safety hazards associated with productivity pressures in health care.
    Back To Top
    Terms and Conditions | Privacy Policy | External Link Disclaimer | RSS Feed

    Connect With Us

    Facebook Twitter You Tube LinkedIn

    Sign up for Email Updates

    Agency for Healthcare Research and Quality

    5600 Fishers Lane
    Rockville, MD 20857
    Telephone: (301) 427-1364

    Submit Your Innovations