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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 - 20 of 72 Results

NIHCM Foundation. Washington DC: National Institute for Health Care Management. August 2, 2022.

Preventable maternal morbidity is an ongoing challenge in the United States. This infographic shares general data and statistics that demonstrate the presence of racial disparities in maternal care that are linked to structural racism. The resource highlights several avenues for improvement such as diversification of the perinatal staffing and increased access to telehealth.
Horsham, PA: Institute of Safe Medication Practices; 2021
Long-term care patients often have concurrent conditions that increase their risk of medication error. This fact sheet provides a list of potential high-alert medications prevalent in long-term care settings that should be administered with particular care due to the heightened potential for harm. A past PSNet perspective discussed medication safety in nursing homes.
Oakbrook Terrace, IL: Joint Commission. 2002-2020.
A series of patient safety brochures, videos and infographics directed toward specific areas of care that encourages patients to take an active role by asking questions and addressing problems with their providers. Topics include preventing falls, medication safety, and safe surgery. Available in both English and Spanish.
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.
Rockville, MD: Agency for Healthcare Research and Quality; March 2020. AHRQ Publication No. 20-0030.
Patient safety organizations (PSOs) collect and analyze protected incident data from across the United States. Expert analysis of PSO data can be utilized to inform design and implementation of local initiatives. This brochure provides guidance for health care organizations regarding benefits of working with a PSO and what to consider when choosing one.
Canadian Institute for Health Information. Ottawa, ON: Canadian Institute for Health Information; 2019.
This fact sheet presents a comparative analysis of 57 health indicators across 12 countries worldwide and gives Canada's current status on a variety of patient safety measures. While Canada showed strengths in reporting and responding to incidents, the data revealed a 14 percent increase in retained foreign objects since the previous analysis. 
Horsham, PA: Institute for Safe Medication Practices; 2019.
Hospitalized patients are at risk for medication errors. This set of tips seeks to help hospitalized patients contribute to the safe use of medications in their care. Recommendations include that patients know the reason they are taking each medication, speak up if any medications look different than previously, and talk with pharmacists when picking up discharge medications.

Agency for Health Research Research and Quality.

The AHRQ Health Literacy Universal Precautions Toolkit, 2nd edition, can help primary care practices reduce the complexity of health care, increase patient understanding of health information, and enhance support for patients of all health literacy levels.
SIS Patient Safety Committee. Spine Intervention Society.
This resource provides newsletters that target concerns associated with spinal pain interventions and offers safety strategies. The collection focuses on three primary areas: procedural contraindications, procedure-related complications, and injectate-related complications such as the safe use of multi-dose and single-dose vials.
Horsham, PA; Institute for Safe Medication Practices: February 2019.
Drawing on information gathered from the ISMP Medication Errors Reporting Program, this fact sheet provides a comprehensive list of commonly confused medication names, including look-alike and sound-alike name pairs. Drug name confusion can easily lead to medication errors, and the ISMP has recommended interventions such as the use of tall man lettering in order to prevent such errors. An error due to sound-alike medications is discussed in this AHRQ WebM&M commentary.
Horsham, PA; Institute for Safe Medication Practices: 2018.
This fact sheet lists medications with a high risk of causing significant harm to patients when incorrectly administered. The 2018 publication reflects insights gathered through a survey of current medication use in acute care facilities. The update includes changes such as expanded examples of antithrombotic agents listed and removal of IV radiocontrast media due to lack of errors reported with its use.
Patient Safety and Risk Management Service Delivery and Safety. Geneva, Switzerland; World Health Organization: August 2019.
This publication highlights statistics that illustrate the global impact of patient harm. The information provided includes the number of hospitalized patients injured during the care process, global costs of medication-related harms, and risks associated with radiation use.
University of Utah Drug Information Service; ASHP; American Society of Health-System Pharmacists.
Efforts to limit the availability of opioids has led to a shortage of needed medications. This fact sheet provides strategies for organizations who seek to improve management of injectable opioids while taking into account both safety and supply availability.
Philadelphia, PA: Pew Charitable Trusts; September 6, 2016.
The usability of electronic health record (EHR) systems can affect clinicians' ability to provide safe patient care. This fact sheet summarizes the results of a stakeholder meeting that explored usability problems and identified three improvement strategies that focused on effective testing, user assessment of EHR safety, and sharing of lessons learned.
Institute for Safe Medication Practices. June 2016.
Mistakes associated with look-alike medication names are a safety concern in health care. Tall Man lettering is one recommended strategy to reduce confusion associated with similarities in drug names. This list includes medications recognized by clinicians and professional organizations as those suited for the application of Tall Man lettering to make their use safer.

Rockville, MD: Agency for Healthcare Research and Quality; December 2014.

Standardization has been embraced as a strategy to improve health literacy and to reduce patient misunderstanding of medication instructions. This tool provides standard language that clarifies directions for patients regarding when they should take their medications.
Silver Spring, MD: United States Food and Drug Administration; October 31, 2014.
Studies have shown that pharmacist involvement can prevent medication errors. To help patients take their medications safely, this consumer update discusses pharmacists as participants in a government drug information center and reveals the top five questions submitted along with their corresponding answers.