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
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Narrow Results By
Search By Author(s)
PSNet Original Content
Additional Filters
Displaying 1 - 20 of 36 Results
Kwok CS, Bennett S, Azam Z, et al. Crit Pathw Cardiol. 2021;20:155-162.
Misdiagnosis of cardiovascular conditions can lead to serious patient harm. This systematic review found that misdiagnosis of acute myocardial infarction (AMI) occurs in approximately 1-2% of cases, and AMI is commonly diagnosed as other heart conditions, musculoskeletal pain, or gastrointestinal disease. The authors suggest that there are opportunities to reduce cases of missed AMI with better education about atypical symptoms and improved training of electrocardiogram interpretation.
Azam I, Gray D, Bonnett D et al. Rockville, MD: Agency for Healthcare Research and Quality; February 2021. AHRQ Publication No. 21-0012.
The National Healthcare Quality and Disparities Reports review analysis specific to tracking patient safety challenges and improvements across ambulatory, home health, hospital, and nursing home environments. The most recent Chartbook documented improvements in approximately half of the patient safety measures tracked. This set of tools includes summaries drawn from the reports for use in presentations to enhance distribution and application of the data.
Battles J, Azam I, Grady M, Reback K, eds. Rockville, MD: Agency for Healthcare Research and Quality; 2017. AHRQ Publication No. 17-0017-EF.
… influence accountability and compensation for errors. … Battles J, Azam I, Grady M, Reback K, eds. Rockville, MD: Agency for … AHRQ … JIMKBattlesAzamGradyRebackBJ B BattlesI AzamM GradyK Reback
Mody L, Greene T, Meddings J, et al. JAMA Intern Med. 2017;177:1154-1162.
Catheter-associated urinary tract infections are considered preventable never events. This pre–post implementation project conducted in long-term care facilities employed a multimodal intervention, similar to the Keystone ICU project. This sociotechnical approach included checklists, care team education, leadership engagement, communication interventions, and patient and family engagement. The project was conducted over a 2-year period across 48 states. In adjusted analyses, this effort led to a significant decrease in catheter-associated urinary tract infections, despite no change in catheter utilization, suggesting that needed use of catheters became safer. A related editorial declares this project "a triumph" for AHRQ's Safety Program for Long-term Care.
Perspective on Safety February 1, 2017
… and Implementation IMPAQ International, LLC … James B. Battles, PhD … Agency for Healthcare Research and Quality … 2006:21-37. ISBN: 9780805848854. 2. King H, Battles J, Baker DP, et al. TeamSTEPPS: Team Strategies and Tools to …
This piece outlines 10 insights about team training in health care learned from experience with the AHRQ-supported teamwork training program, TeamSTEPPS.
Dr. Edmondson is the Novartis Professor of Leadership and Management at Harvard Business School. She is an expert on leadership, teams, and organizational learning. We spoke with her about the role of teamwork in health care and why it is becoming increasingly important.

Ridgely MS, Greenberg MD, Clancy CM, eds. Health Serv Res. 2016;51(suppl 3):2395-2648.

… … DM … JL … IZ … JF … C … P … MJ … A … EW … SK … EJ … JM … B … AM … MJ … ML … H … SJ … JT … MM … BF … LA … BL … TB … NM … KM … DK … YJ … DM … Y … PI … TH … SK … JS … MS … MD … MB … J … W … JW … KK … K … R … JH … M … S … LW … M … WM … MC … GD … P … N … JM … SJ … BattlesRebackAzam … Boothman … Burstein … Zalenski … …
Classen D, Munier W, Verzier N, et al. J Patient Saf. 2021;17:e234-e240.
The Medicare Patient Safety Monitoring System was developed to track adverse events nationally to support robust safety improvement. This review summarizes the history of the Medicare Patient Safety Monitoring System and its evolution into a new system that seeks to enhance the standardization and utilization of the collected data.
Saint S, Greene T, Krein SL, et al. New Engl J Med. 2016;374:2111-2119.
The landmark Keystone ICU study, which achieved remarkable sustained reductions in central line–associated bloodstream infections in intensive care unit (ICU) patients, stands as one of the most prominent successes of the patient safety field. Although the use of a checklist gathered the most publicity, the study's key insight was that preventing health care–associated infections (HAIs) required extensive attention to improving safety culture by addressing the socioadaptive factors within hospitals that contributed to HAIs. In this new AHRQ funded national study, the Comprehensive Unit-based Safety Program was implemented at 603 hospitals in 32 states, with the goal of preventing catheter-associated urinary tract infections in ICU and ward patients. The effort involved socioadaptive interventions (various approaches shown to improve safety culture) and technical interventions (targeted training to reduce usage of indwelling urinary catheters and providing regular data feedback to participating units). Catheter usage and infection rates significantly decreased in ward patients, although no change was found in ICU patients. This study thus represents one of the few safety interventions that has achieved a sustainable improvement in a clinical outcome. An earlier article described the implementation of the program, which involved collaboration between state and national agencies and academic centers. In a 2008 PSNet interview, the study's lead author discussed his work on preventing HAIs.

Battles JB, Cleeman JI, Kahn KL, Weinberg DA, eds. Am J Infect Control. 2014;42(suppl 10):S189-S296.

… well as catheter-associated urinary tract infections . … Battles JB, Cleeman JI, Kahn KL, Weinberg DA, eds. Am J Infect Control. 2014;42(suppl 10):S189-S296. … McMahon LF Jr … JB … JI … KL … DA … P … B … Y … MB … MG … SL … B … SR … S … YJ … K … T … MD … BC … …

Battles JB, Cleeman JI, Kahn KL, Weinberg DA, eds. Infect Control Hosp Epidemiol. 2014;35(suppl 3):S1-S141.

… programs influence HAI prevention and research. … Battles JB, Cleeman JI, Kahn KL, Weinberg DA, eds. Infect … … S … A … ML … Y … MM … D … L … N … E … EJ … MK … K … TR … J … RA … JJ … A … K … RE … JA … JB … R … SS … GM … T … R … … DJ … M … JE … KA … TE … JS … JL … PA … AR … RW … RC … JS … B … R … P … E … Y … H … S … Battles … Cleeman … Kahn … …
Battles JB, Cleeman JI, Kahn KL, Weinberg DA, eds. Rockville, MD: Agency for Healthcare Research and Quality; June 2014. AHRQ Publication No. 14-0003.
… urinary tract infections . A recent AHRQ WebM&M perspective reviews how infection prevention fits into a safety program. … Battles JB, Cleeman JI, Kahn KL, Weinberg DA, eds. Rockville, … Research and Quality; AHRQ … JB … JI … KL … DA … Battles … Cleeman … Kahn … Weinberg … JB Battles … JI Cleeman …
Sharp D, Palmore T, Grady C. Infect Control Hosp Epidemiol. 2014;35:307-9.
Engaging patients in health care–acquired infection (HAI) prevention, such as asking providers about hand hygiene compliance, has shown promise. This commentary recommends providing patients with information about infection risks and hospital policies as additional areas to involve patients in reducing HAIs.
Wang Y, Eldridge N, Metersky M, et al. N Engl J Med. 2014;370:341-51.
The effects of more than a decade of national efforts dedicated to improve patient safety remain largely unclear. This study used the Medicare Patient Safety Monitoring System (MPSMS) database to assess national trends in adverse event rates between 2005 through 2011 for patients hospitalized with acute myocardial infarction, congestive heart failure, pneumonia, or conditions requiring surgery. The analysis included a large study sample with more than 60,000 patients across 4372 hospitals. The results show a significant decline in adverse event rates for acute myocardial infarction and congestive heart failure, translating to an estimated 81,000 in-hospital adverse events averted in 2010–2011. However, there were no measurable overall improvements for patients admitted with pneumonia or surgical conditions. Some events, such as pressure ulcers in surgical patients, actually increased despite considerable national attention to these problems. This study suggests that national patient safety initiatives have led to real progress in some areas but have not created across-the-board improvements.
Berenholtz SM, Lubomski LH, Weeks K, et al. Infect Control Hosp Epidemiol. 2014;35:56-62.
The continued progress in eliminating central line–associated bloodstream infections (CLABSIs) in intensive care units (ICUs) stands as one of the patient safety movement's major successes. The initial efforts to prevent CLABSI in the ICU at Johns Hopkins Hospital, championed by Dr. Peter Pronovost, were subsequently replicated in the landmark Keystone ICU project in Michigan. This study describes the results of an AHRQ-funded effort to extend the Keystone ICU approach nationwide, attempting to prevent infections in more than 1000 ICUs in 44 states. The initiative, which combined the well-publicized infection control checklist with interventions to enhance safety culture (such as the comprehensive unit-based safety program) and continuous data measurement and feedback, achieved a reduction in CLABSI rates of more than 40%. This remarkable series of interventions exemplifies the value of using a sociotechnical approach to improving safety and has likely saved thousands of lives.
Farley DO, Haviland AM, Haas A, et al. BMJ Qual Saf. 2011;21.
All hospitals are required to maintain a voluntary error reporting system, and such systems serve an important role in detecting safety problems. However, prior research has extensively documented the limitations of such systems. The success of a reporting system rests on four key components, including a supportive safety culture and an effective mechanism for acting on reported issues. This AHRQ-funded survey of risk managers found that most hospitals' systems did not meet these effectiveness criteria, although some improvement had taken place between 2005 and 2009. Proposals for improving the utility of error reporting systems are advanced in a recent AHRQ WebM&M perspective and interview.
Pham JC, Gianci S, Battles J, et al. Qual Saf Health Care. 2010;19:446-51.
Voluntary error reporting systems are perhaps the most controversial of the available tools for detecting patient safety incidents. A sizable body of research has characterized the limitations of such systems, but they remain a cornerstone of safety efforts at many institutions. This consensus conference, sponsored by the World Alliance for Patient Safety, drew together an international group of error reporting experts in order to develop a learning community for incident reporting. The ultimate goal was to develop guidelines for effective use of reporting systems to improve safety. Discussing the advantages and challenges of current reporting systems, this article proposes guidelines for maximizing incident reporting utility (based on a previously published framework). A previous article discussed the use of different types of reporting systems to obtain a comprehensive view of patient safety within an institution.