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 1166 Results

Safety Management Systems - an Introduction for Healthcare.

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Dorset, UK: Health Services Safety Investigations Body; October 2023.

Safety management systems (SMS) are employed in many high-risk industries, yet are not fully adopted in health care. This investigation report discusses the core safety elements of an SMS (policy, risk management, assurance, and promotion), how they are defined in a wide range of industries, and how they might be systemically embedded in the care environment to support safety culture, accountability, and maturity.

Deficiencies in Quality Management Processes and Delays in the Communication of Test Results and Follow-Up Care at the Phoenix VA Health Care System in Arizona.

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Washington DC; VA Office of the Inspector General; October 31, 2023; Report no. 22-03599-07.

Disclosure failures detract from learning, appropriate incident examination, and safe care delivery. This report examined factors contributing to poor disclosure practices associated with the care of three patients. Lack of report submission, uninitiated root cause analysis, and inadequate documentation were process weaknesses highlighted by the review.

State of Care.

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

This website provides access to an annual report that summarizes National Health Service hospital and social care performance across a range of care quality metrics at both the trust and service level. The 2022-2023 report found substantial weaknesses in specialty areas such as emergency and maternal care and recognized workforce wellbeing issues that impact access and quality.

NPSD Data Spotlight: Patterns of Fall Interventions.

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Rockville, MD: Agency for Healthcare Research and Quality; September 2023. AHRQ Publication no. 23-0055.

Falls are a frequently reported sentinel event. This Data Spotlight from AHRQ’s Network of Patient Safety Databases (NPSD) highlights the most common interventions in place among patients who experienced a fall such as nonslip wear, bed height and visible risk identification. Data for the analysis includes reports on patient safety concerns submitted from 2009 through 2021.

Medication Safety for Look-alike, Sound-alike Medicines.

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Galappatthy P, Mair A, Dhingra-Kumar N et al. Geneva, Switzerland: World Health Organization; 2023. ISBN 9789240058897.

Look-alike, sound-alike (LASA) medicines are known contributors to drug errors. This report discusses how name and label similarities degrade care, and the actions organizations and individual practitioners can take to mitigate the potential of LASA medication errors that cause harm. The authors discuss obstacles and enablers to implementing prevention strategies.

Advancing Diagnostic Excellence for Maternal Health Care: Proceedings of a Workshop–in Brief.

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National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2023. ISBN: 9780309711937.

Maternal health care is rapidly emerging as a high-risk service that is vulnerable to communication, equity, and diagnostic challenges. This report examines the role of disparities in care across the maternal care continuum and strategies to drive diagnostic improvement such as care bundles, midwives, and health information technology. This publication is from a series of programs and resultant publications on improving diagnostic excellence.

Network of Patient Safety Databases Chartbook.

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Rockville, MD: Agency for Healthcare Research and Quality; September 2023. AHRQ Publication no. 23-0082.

The sharing of data is a core element of a learning health system. AHRQ has released the Network of Patient Safety Databases (NPSD) Chartbook 2023, which offers an overview of nonidentifiable, aggregated patient safety event and near-miss information, voluntarily reported by AHRQ-listed Patient Safety Organizations across the country between June 2014 and December 2022. The chartbook outlines the extent of harm reported, distribution of patient safety events, near misses, and unsafe conditions.

Home Health Agencies Failed To Report Over Half of Falls With Major Injury and Hospitalization Among Their Medicare Patients.

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Maxwell A. Washington DC: Office of Inspector General; September 2023. Report no. OEI-05-22-00290.

Falls are a persistent threat to patient safety and effective reporting of this adverse event can assist in understanding important gaps in care. This report examines the incidence of Medicare home health patients experiencing falls with major injury resulting in hospitalization that were not reported as required. 55% of falls were not documented thusly negatively impacting the viability of Care Compare as a reliable public resource for this information.

Adverse Events.

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United States Office of the Inspector General: 2010-2023.

Large-scale data analysis provides insights to generate evidence-based improvement action. This collection of reports provides access to investigations of the impact of healthcare-related harm events in Department of Health and Human Services (HHS) programs and across the United States health system. This set of publications not only examines weaknesses but provides recommendations for improvement on topics such as gaps in fall reporting by home health agencies, Medicare adverse events and the viability of payment incentives as a strategy for medical harm reduction.

Making Healthcare Safer IV: A Continuous Updating of Patient Safety Harms and Practices.

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Rockville, MD: Agency for Healthcare Research and Quality: November 2023.

Patient safety progress is dynamic, consistently producing evidence for application to generate improvements. This report is the fourth in a series funded by the Agency for Healthcare Research and Quality to track a prioritized set of emerging and existing safety approaches to confirm their value and effectiveness. This report will be compiled as new conclusions are formulated. Each review will be posted to the collection as they are completed. The first three Making Healthcare Safer reports, published in 2001, 2013, and 2020, have each served as a consolidated evidence source for clinicians, health system leadership, researchers, and government agencies. Chapter protocols and the results of an examination on patient and family engagement and report cards as a surgical improvement mechanism are now available.

Rethinking Patient Safety: A Discussion Guide for Patients, Healthcare Providers and Leaders.

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Gilbert R, Asselbergs M, Davis D, et al. Healthcare Excellence Canada; 2023.

Patient safety requires a systems approach to identify problems and arrive at lasting solutions that reduce harm. This document encourages discussion amongst a broad base of stakeholders to address all forms of harm, such as discrimination, inequality, and psychological stress, in addition to physical injury. The resource insists these components be incorporated in work to close quality and safety gaps across the health care system.

Deficiencies in Facility Leaders' Response to Critical Surgical Events at the Michael E. DeBakey VA Medical Center in Houston, Texas.

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Washington, DC: The Veterans Affairs Inspector General. October 4, 2023. Report No. 23-00080-227.

Wrong-site surgery and unintentionally retained surgical items are considered never events. This report details five wrong-site surgeries and three instances of retained surgical items at one VA medical center between 2018 and 2022. The findings suggest that timely investigation into events from 2018-2021 may have prevented three incidents in 2022. Additionally, the medical center failed to fully report the provider responsible for three of the wrong-site surgeries.

MHA and MHA Keystone Center Annual Reports.

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Okemos, MI: Michigan Health & Hospital Association.

This publication annually reports on the successful outcomes of the Michigan Keystone Center collaborative activities. The achievements noted in the 2022-2023 data review include reduction of MHA Keystone Center PSO members have significantly reduced both fall and blood or blood product events reported to the state patient safety organization reporting system. Areas of focus for improvement work reported on include health equity, workforce wellbeing, and maternal health.

Ranking of the Rate of State Medical Boards’ Serious Disciplinary Actions, 2019-2021.

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Wolfe SW, Oshel RE. Washington, DC: Public Citizen; August 16, 2023.

There are recognized systemic weaknesses in identification and disciplinary programs addressing clinicians with poor performance records. This report examines the effectiveness of state medical-licensing boards as responsible parties to tracking problematic physicians. The reduction of variation in processes across various states, involvement of patients on review boards, and increased use of the National Practitioner Data Bank are suggested improvement strategies.

Right Kind of Wrong: Why Learning to Fail can Teach us to Thrive.

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Edmondson A. Atria Books, New York, 2023. ISBN: 9781982195069.

Despite the harm that failure can cause, its value as a learning opportunity, if examined through the lens of human error rather than blame, cannot be understated. This book explores how failure that happens in new situations provides new insights toward goal achievement, utilizes knowledge and capitalizes on even small missteps, and can enhance and inform improvement.

Patient Safety: A Case-based Innovative Playbook for Safer Care. Second Edition.

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Agrawal A, Bhatt J, eds. Cham, Switzerland, Springer Nature; 2023. ISBN: 9783031359330.

This publication describes and analyzes clinical cases to illustrate patient safety concepts and types of medical errors to engage clinicians in improvement work. The second edition includes chapters devoted to safety challenges that emerged in prominence due to the COVID-19 pandemic (health disparities, inequities and nursing home care failures), as well as core topics such as high reliability, human factors engineering and the opioid epidemic.

Patient Engagement for Patient Safety: The Why, What, and How of Patient Engagement for Improving Patient Safety.

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Kendir C, Fujisawa R, Brito Fernandes O, et al. Paris, France: OECD Publishing; 2023. OECD Health Working Papers, No. 159.

Patient and family engagement can improve individual health outcomes and may help identify potential safety hazards. This report describes the economic impact of patient engagement, results of pilot data collection to measure patient-reported experiences of safety, and the status of patient engagement in 21 countries.

Adverse Health Events in Minnesota: Annual Reports.

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St Paul, MN: Minnesota Department of Health.

The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery. Since 2003, Minnesota hospitals have been required to report such incidents. The 2022 report summarizes information about 572 adverse events that were reported, representing a significant increase in the year covered. Earlier reports prior to the last two years reflect a fairly consistent count of adverse events. The rise documented here is likely due to demands on staffing and care processes associated with COVID-19 and general increases in patient complexity and subsequent length of stay. Pressure ulcers and fall-related injuries were the most common incidents recorded. Reports from previous years are available.

Maryland Hospital Patient Safety Program Annual Report.

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Office of Health Care Quality. Baltimore, MD: Maryland Department of Health and Mental Hygiene.

This annual report summarizes never events in Maryland hospitals over the previous year. During fiscal year 2022, reported events increased due to the COVID pandemic, workforce shortages and other system demands. Events contributing to patient deaths and severe harm from preventable medical errors during the time period doubled. The authors recommend several corrective actions to enhance improvement work, including board and executive leadership engagement in safety work and application of high-reliability concepts to enhance safety culture.

Fragmented: A Doctor's Quest to Piece Together American Health Care.

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Yurkiewicz I. New York, NY: WW Norton & Company, Inc; 2023. ISBN: 9780393881196.

Disjointed health care processes contribute to missed test results, incomplete communication, and care omissions that harm patients. This book shares a personal account of how broken care processes serve as a core deterrent in one clinician’s ability to provide the safest care possible.

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