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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 - 18 of 18 Results

US Senate Finance Committee. 117th Cong (2021-2022). August 3, 2022.

Organ transplantation processes require reliable communication and technical expertise to ensure safety for organ delivery and patient care. This hearing discussed the findings of a United States Senate investigation into waste and harm in the US organ transplant system. Blood-type mistakes, transport failures, and process challenges were amongst the problems discussed.

US Senate Committee on Veterans Affairs. 117th Cong (2021-2022). (July 20, 2022).

Large-scale electronic health record (EHR) implementation projects encompass a myriad of problems to navigate to arrive at success. This Congressional panel explores challenges experienced during EHR implementation in the VA Health system. Panelists from the Veterans Administration, the investigator and the technology vendor involved in the program shared insights and next steps to direct improvement.

US House of Representatives Committee on Veterans' Affairs Subcommittee on Health.  117th Cong. 1st Sess (2021).

The Veterans Health Administration is a large complex system that faces various challenges to safe care provision. At this hearing, government administrators testified on current gaps that detract from safe care in the Veteran’s health system. The experts discussed several high-profile misconduct and systemic failure incidents, suggested that the culture and leadership within the system overall enables latency of issues, and outlined actions being taken to address weaknesses.
US House of Representatives Committee on Veterans Affairs Subcommittee on Oversight and Investigations. 116th Cong, 1st Sess (2019).
The Veterans Affairs (VA) health system is responsible for both systemic achievements and challenges. This hearing examined a series of problems occurring in the VA system including unexplained deaths of patients. Strategies presented during testimony to remedy these situations include improving employee background checks, credentialing gaps and response to reported clinician performance concerns.
Full Committee Hearing. US Senate Committee on Health, Education, Labor and Pensions (September 16, 2015)
Enabling patients to access their medical records has been found to enhance patient–clinician communication and uncover errors. This hearing explored the importance of providing patient access to personal health information to improve care. Testimonies discussed the need to have one integrated patient record and to design patient portals around human factors approaches to augment usability.
Hearing Before the Committee on Veterans' Affairs United States Senate. 113th Cong (September 9, 2014).
In this hearing Veterans Affairs leadership provide an update on the current investigation into data and scheduling manipulation in the VA system. The testimonies discuss the scope of the problem, suggest that the culture at the hospitals enabled record falsification to become normalized, and outline actions being taken to address weaknesses in processes and access to care.
Hearing Before the Subcommittee on Primary Health and Aging, 113th Cong (July 17, 2014).
A group of patient safety experts, including Drs. Peter Pronovost, Ashish Jha, and Tejal Gandhi, testified to Congress that more must be done to track and prevent widespread patient harms. The title of the hearing was based on the seminal study estimating that as many as 200,000 to 400,000 patients experience harms that contribute to their death each year. The medical experts recounted the lack of significant progress since the landmark Institute of Medicine report in 1999, and they called on Congress to task the Centers for Disease Control and Prevention with tracking medical errors and patient harm. Dr. John James, a scientist who became engaged in patient safety efforts following the death of his son due to medical errors, recommended that lawmakers establish a National Patient Safety Board, similar to the current National Transportation Safety Board. A prior AHRQ WebM&M perspective discussed the many challenges of measuring patient safety.
Testimony before the Committee on Health, Education, Labor, and Pensions, US Senate. US Government Accountability Office. GAO-12-315T (December 15, 2011)
This testimony details the US Food and Drug Administration (FDA) response to drug shortage trends and advocates for the agency to have more leverage with manufacturers to address burgeoning shortages.

Hearings before the Subcommittee on Health of the Committee on Energy and Commerce Committee, 112th Cong, 1st Sess (September 23, 2011).

This hearing focused on the problem of medication shortages and its impact on patients, hospitals, and providers.
Subcommittee on Health Care, Committee on Finance, US Senate, Government Accountability Office, GAO-09-516T (March 18, 2009)
This Congressional testimony summarizes a 2008 investigation and responds to its findings. It suggests that prioritization of effort, data consistency, and data compatibility are needed to improve health care–associated infection reduction efforts.
Washington, DC: United States Government Accountability Office; March 31, 2008. Publication GAO-08-283.
This report examines US government standards, procedures, and data collection methods related to health-care-associated infections (HAI) and recommends increased integration across program databases.
U.S. Department of Veterans Affairs. Hearing before the Committee on Veterans’ Affairs, House of Representatives, Subcommittee on Oversight and Investigations. 109 Congress, 2nd sess June 15, 2006. Washington, DC: US Government Printing Office; 2007.
These testimonies addressed issues within the Veterans Affairs health system that contributed to recent sterilization and labeling lapses.
This hearing provides testimony from the Agency for Healthcare Research and Quality, the Joint Commission on Accreditation of Healthcare Organizations, the American College of Surgeons, the Medical Association of Georgia, and the National Partnership for Women & Families on the current state of patient safety and quality as well as suggested areas for improvement.