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 1132 Results

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.

Serious Reportable Events in Massachusetts.

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Fillo KT, Saunders K. Bureau of Health Care Safety and Quality, Department of Public Health. Boston, MA: Commonwealth of Massachusetts; 2023.

This reoccurring report compiles patient safety data collected by Massachusetts hospitals. The 2022 numbers document an increase in serious reportable events recorded in acute care hospitals, from 1430 the previous year to 1632. This presentation also includes events from ambulatory surgery centers. Older reports are also available.

Non-accidental Injuries in Infants Attending the Emergency Department.

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Farnborough, UK: Healthcare Safety Investigation Branch; April 2023.

Misattribution of child maltreatment injuries can be a serious misdiagnosis affecting families and patients. This report analyzes ten safety incident reports from across the British National Health Service to explore how non-accidental injury was missed. Themes identified as contributing to the problems include lack of information sharing, inconsistent guidance, and emergency department care demands.

Lessons from the Covid War: An Investigative Report.

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Covid Crisis Group. New York: Public Affairs; 2023. ISBN‏: ‎9781541703803.

The transfer of failure experiences to generate learning and improve service is a complicated responsibility. This book examines breakdowns in the US response to the COVID-19 epidemic to understand causes of the problems, in order to better prepare health care, government, and public health systems for future pandemics. It also discusses what successes were achieved and how to capitalize on those improvements.

Curated Libraries

Implementation of Patient Safety Projects Curated Library

May 4, 2023

The implementation of effective patient safety initiatives is challenging due to the complexity of the health care environment. This curated library shares resources summarizing overarching ideas and strategies that can aid in successful program execution, establishment, and sustainability.

Burnout in Primary Care: Assessing and Addressing It in Your Practice.

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Gerteis J, Booker C, Brach C, et al. Rockville, MD: Agency for Healthcare Research and Quality; February 2023. AHRQ Publication No. 23-0025.

Burnout reduction in primary care is critical to patient safety. This resource is designed to help practices assess the causes of burnout in primary care and implement strategies to promote well-being. Suggested areas of focus include the reduction of documentation tasks, use of huddles and peer support.

Roadmap to Health Care Safety for Massachusetts.

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Massachusetts Healthcare Safety and Quality Consortium. Boston, MA: Betsy Lehman Center for Patient Safety; April 2023.

Collective engagement and focus are required to attain large system change. This plan centers on five goals to improve patient safety in Massachusetts: leadership and culture, operations and engagement, patient and family support, workforce wellbeing, and measurement and transparency. The document provides guidance for implementation of strategies targeting each goal to generate sustainable improvements.

Patient Safety Authority Annual Reports.

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Pennsylvania Patient Safety Authority. Harrisburg, PA: Patient Safety Authority; April 2023.

This report summarizes patient safety improvement work in the state of Pennsylvania. It reviews the 2022 activities of the Patient Safety Authority that reflected a strategic emphasis on reporting compliance and data quality. Additional sections cover educational, publication, and learning management system efforts.

Safety Risk of Air Embolus Associated with Central Venous Catheters Used for Haemodialysis Treatment.

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Farnborough, UK: Healthcare Safety Investigation Branch. March 2023.

Patients receiving hemodialysis are at risk of complications, including air embolus. This report describes how unfamiliar equipment and lack of standardized training contributed to the death of a dialysis patient due to air embolus. Safety recommendations include changes in medical education on how to handle uncertainty in clinical settings and amending dialysis guidelines to include risk of air embolus associated with unclamped central venous catheters.

Your Safety in our Hands in Hospital.

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Patient Safety Surveillance Unit. Department of Health, Perth: Western Australia.

This annual report shares the results of Western Australia's sentinel event reporting program. Medication errors were the highest recorded sentinel event in the latest period. The data is placed in the context of the overall data collected over the last 5 years of the program.

Deficiencies in Emergent and Outpatient Care of a Patient with Alcohol Use Disorder at the Richard L. Roudebush VA Medical Center in Indianapolis, Indiana.

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Washington, DC: VA Office of the Inspector General; March 29, 2023. Report no. 21-03680-80.

Care systems for alcohol use disorder (AUD) patients are suboptimal. This report examines the case of a patient with AUD whose emergency care was mismanaged, uncoordinated, and incomplete, contributing to his death two days after discharge. The safety recommendations shared include improving discharge planning, assessment, and consideration of mental health conditions when caring for AUD patients.

ISMP Targeted Medication Safety Best Practices for Community Pharmacy.

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Horsham, PA; Institute for Safe Medication Practices: April 2023.

Community pharmacies are common providers of medication delivery that harbor process weaknesses affecting safety. This guidance shares evidence-based steps to address problems such as wrong patient errors and lack of consistent barcode system use in the community setting.

Listening, Learning, Responding to Concerns.

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Newcastle Upon Tyne, UK: Care Quality Commission; March 2023.

The ability to raise patient safety concerns without fear of retribution is a core element of a safety culture. This pair of reports examines a failure in organizational response to an employee expressing concerns. The first report examines an explicit whistleblowing incident in the National Health Service that was poorly managed. The second looks at broader system-level elements needed to support effective responses when concerns are voiced.

Care Delivery within Community Mental Health Teams.

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Farnborough, UK: Healthcare Safety Investigation Branch; March 2023.

Patient suicide is a sentinel event. This report examines a suicide incident that identified problems with risk assessment and identification, family engagement, and medication management in the context of mental health provision when supporting patients in psychological distress.

National Healthcare Quality and Disparities Report Chartbook on Patient Safety.

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Rockville, MD: Agency for Healthcare Research and Quality; March 2023. AHRQ Pub. No. 23-0032.

The Network of Patient Safety Databases (NPSD) serves a central role in understanding the current state of care as tracked by patient safety measures. The 2023 Chartbook offers an overview of nonidentifiable, aggregated patient safety event, and near-miss information, voluntarily reported to data collection initiatives across the United States between 2000 and 2020. The Chartbook includes a summary of trends, disparities findings, and figures illustrating select patient safety measures.

AMA Prior Authorization (PA) Physician Survey.

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Chicago, IL: American Medical Association; March 2023.

Insurance policies can have consequences that reduce the safety of medical care. This latest version of the study surveyed 1000 physicians in 2022 to find that prior authorization requirements contributed to patient harm or potentially preventable hospitalization 33 percent of the time.

The Leapfrog Hospital Survey.

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Leapfrog Group.

This website offers resources related to the Leapfrog Hospital Survey investigating hospitals' progress in implementing specific patient safety practices. Updates to the survey include increased time allotted to complete computerized provider order entry evaluation, staffing of critical care physicians on intensive care units, and use of tools to measure safety culture. Reports discussing the results are segmented into specific areas of focus such as health care-associated infections and medication errors. The 2023 survey session opens April 1, 2023.

Top 10 Patient Safety Concerns.

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Plymouth Meeting, PA: ECRI; March 2023.

The global COVID-19 pandemic continues to exacerbate weaknesses in care that can contribute to harm. ECRI presents the top ten patient concerns for 2023, including pediatric mental health care, workplace violence, care coordination, and patient medication list mistakes.

Curated Libraries

Value and Patient Safety

March 8, 2023

Value as an element of patient safety is emerging as an approach to prioritize and evaluate improvement actions. This library highlights resources that explore the business case for cost effective, efficient and impactful efforts to reduce medical errors.

Inadequate Outpatient Mental Health Triage and Care of a Patient at the Chico Community-Based Outpatient Clinic in California.

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Washington, DC: VA Office of the Inspector General; February 2, 2023. Report no. 22-01363-52.

Gaps in care for psychologically vulnerable patients can result in harm to family members and self-harm. This report examines organizational failures in responding to staff and clinical leaders’ concerns regarding access, triage, and care continuity for mental health patients. Recommendations for improvement include same-day access to appropriate specialty care, medication management, and risk documentation.

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