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
Approach to Improving Safety
Displaying 1 - 20 of 97 Results
Perspective on Safety September 1, 2019
… this need by funding the development of AHRQ WebM&M (initially funded September 2001; launched February 2003) … University of California, San Francisco … Robert M. Wachter, MD … Professor and Chair, Department of Medicine … San Francisco … Sumant … Robert … Ranji … WachterR. … Sumant R. Ranji … Robert Wachter
This piece explores the evolution of PSNet and WebM&M since their inception (WebM&M in 2003 and PSNet in 2005) and summarizes changes in the patient safety landscape over time.
Perspective on Safety November 1, 2018
This piece, written by the physician who coined the term "hospitalist," provides an overview of the hospitalist model and reflects on key advantages of and challenges faced by the Comprehensive Care Physician Model.
This piece, written by the physician who coined the term "hospitalist," provides an overview of the hospitalist model and reflects on key advantages of and challenges faced by the Comprehensive Care Physician Model.
Dr. Meltzer is the Fanny L. Pritzker Professor of Medicine, Chief of the Section of Hospital Medicine, and Director of the Center for Health and the Social Sciences at the University of Chicago. His research aims to improve the quality and lower the cost of hospital care. We spoke with him about the Comprehensive Care Physician Model, which he pioneered and was recently featured in an article in The New York Times Magazine.
Gandhi TK, Kaplan GS, Leape L, et al. BMJ Qual Saf. 2018;27:1019-1026.
Over the last decade, the Lucian Leape Institute has explored five key areas in health care to advance patient safety. These include medical education reform, care integration, patient and family engagement, transparency, and joy and meaning in work and workforce safety for health care professionals. This review highlights progress to date in each area and the challenges that remain to be addressed, including increasing clinician burnout and shortcomings of existing health information technology approaches. The authors also suggest opportunities for further research such as measuring the impact of residency training programs. In a past PSNet interview, Dr. Tejal Gandhi, president of the IHI/NPSF Lucian Leape Institute, discussed improving patient safety at a national level.
Wachter R, Howell MD. JAMA. 2018;320:25-26.
The impact of electronic health records has thus far been disappointing for many clinicians, with limited effect on patient safety and growing concern that electronic health records may contribute to physician burnout. This commentary discusses the productivity paradox of information technology—the fact that digitization often initially impedes productivity rather than enhancing it. The authors highlight recent advancements in health care information technology that hold promise to overcome the productivity paradox, such as artificial intelligence, and discuss barriers that must be surmounted in order for health IT to meet its potential.
Perspective on Safety December 1, 2017
… surgery. His description of one Morbidity and Mortality (M&M) conference captures the zeitgeist. After the case of a … addressed in equally innovative ways. … Robert M. Wachter, MD … Professor and Chair, Department of Medicine … San Francisco … References … 1. Kohn L, Corrigan J, Donaldson M, eds. To Err Is Human: Building a Safer Health …
This piece explores progress of patient safety in the surgical field and where further improvement can be made, such as ongoing assessment of procedural skills along with video recording and review of surgical procedures.
Dr. Bilimoria is the Director of the Surgical Outcomes and Quality Improvement Center of Northwestern University, which focuses on national, regional, and local quality improvement research and practical initiatives. He is also the Director of the Illinois Surgical Quality Improvement Collaborative and a Faculty Scholar at the American College of Surgeons. In the second part of a two-part interview (the earlier one concerned residency duty hours), we spoke with him about quality and safety in surgery.
Gupta R, Moriates C, Harrison JD, et al. BMJ Qual Saf. 2017;26:475-483.
Health care institutions are increasingly focused on providing high-value care and preventing overuse. In this study, researchers developed a validated High-Value Care Culture Survey and found that administering the survey at two large academic medical centers provided health care leaders with an opportunity to target their improvement efforts.
Pannick S, Wachter R, Vincent CA, et al. BMJ. 2016;355:i5417.
Patient safety research and commentary often focus on specialized care processes rather than medical wards. Exploring challenges to improving safety in the medical ward environment, this commentary outlines four strategies to address complexity of implementing initiatives in this setting.

Shekelle PG, Sarkar U, Shojania K, et al. Technical Brief No. 27. Rockville, MD: Agency for Healthcare Research and Quality; October 2016. AHRQ Publication No. 16-EHC033-EF.

Most patient safety research and initiatives have focused on the hospital environment, despite the fact that much of health care is delivered in outpatient settings. This technical brief explores gaps in the evidence base that hinder understanding of safety concerns and factors unique to ambulatory care. The evidence review supports use of pharmacist interventions to augment medication safety in outpatient settings. The authors also found that electronic health records have mixed effects on ambulatory safety. Key informants interviewed for the brief noted that studies on patient engagement and diagnostic error are lacking.
Neuhaus C, Hofer S, Hofmann G, et al. Anesth Analg. 2016;122:2059-63.
Although aviation safety strategies such as checklists and team briefings are widely considered to be valuable in health care, evidence regarding their impact has been mixed. Discussing barriers to surgical team adoption of aviation safety principles, this commentary provides a framework to guide briefings about anesthesia inductions.
Gupta K, Wachter R, Kachalia A. BMJ Qual Saf. 2017;26:164-168.
Although financial incentives have been widely adopted, they may not lead to organizational improvements. This commentary raises concerns about including hospital mortality in incentive programs, since patient deaths do not necessarily mean poor quality care. The authors suggest that further research is needed to enhance accuracy of risk-adjusted mortality and to account for differences in patient treatment preferences.
Perspective on Safety November 1, 2015
… conceived the idea of a web-based morbidity and mortality (M&M) conference soon after the release of the IOM report. My … goal of keeping patients safe from harm. … Robert M. Wachter, MD … Editor, AHRQ Patient Safety Network Professor …
This editorial provides an overview of how PSNet and WebM&M have evolved in the past decade.

Wachter R, Kaplan GS, Gandhi T, et al. Health Affairs Blog. June 22, 2015.

… to achieve greater transparency in their organizations. … Wachter R, Kaplan GS, Gandhi T, et al. Health Affairs Blog . June 22, … … R. … GS … T. … L. … Wachter … Kaplan … Gandhi … Leape … M. … K. … R. M. Wachter … GS Kaplan … T. K. Gandhi … L. Leape …
Pannick S, Davis R, Ashrafian H, et al. JAMA Intern Med. 2015;175:1288-98.
Interdisciplinary team care interventions are increasingly common on medical wards, based partly on a widespread belief that these practices will improve efficiency and patient safety. This systematic review sought to evaluate the performance of hospital-based interdisciplinary teams on patient outcomes. The majority of studies have chosen length of stay, complications, readmission, or mortality rates as their primary outcomes, but interdisciplinary teams rarely seem to affect these traditional quality measures, which may be insensitive to teamwork improvements in care delivery. The authors call for establishing more relevant outcomes to evaluate interdisciplinary team interventions. An accompanying commentary notes that this systematic review provides an opportunity to highlight the potential harms of choosing the wrong metrics to evaluate an intervention, which can undermine a program's mission.