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

Clear all filter(s)

Clear all filter(s)

Displaying 1 - 20 of 255 Results

Few hospitals are willing to bear the cost of providing psychiatric care for kids.

Save to Library

Schorsch K, Karp S. WBEZ Chicago. March 9, 2023.

Pediatric mental health is a patient safety concern. This news story outlines the challenges to available services to address this need, tactics to keep young patients from harming themselves or others, and system-level approaches to improvement.

Feds move to rein in prior authorization, a system that harms and frustrates patients.

Save to Library

Sausser L. Kaiser Health News. March 13, 2023.

Lack of access to appropriate testing, procedures, and medications due to system barriers is a patient safety concern. This article highlights the contribution pre-authorization has on care delivery complexity that can result in patient harm.

I’m an ER doctor: here’s what I found when I asked ChatGPT to diagnose my patients.

Save to Library

Tamayo-Sarver J. Fast Company. March 13, 2023.

Artificial intelligence (AI) harbors risks and biases that can misinform clinicians, researchers, and patients. This article discusses experience with an AI application in the emergency setting and the diagnostic mistakes it made. The author offers caution when proceeding with the use of AI as a diagnostic tool.

In Conversation with Dr. Neal Sikka and Dr. Colton Hood about Remote Patient Monitoring

Save to Library

Perspective on Safety March 15, 2023

Dr. Neal Sikka and Dr. Colton Hood are emergency medicine physicians who work in the Innovative Practice & Telemedicine section at George Washington University Hospital (GW). We spoke with them about their experience implementing remote patient monitoring (RPM) programs, GW’s Maritime Medical Access program, and patient safety considerations in the remote environment.

Remote Patient Monitoring

Save to Library

Perspective on Safety March 15, 2023

This piece discusses the evolution of remote patient monitoring, emergence into use with acute conditions, patient safety considerations, and the continued challenges of telehealth implementation.

Do no unconscious harm.

Save to Library

Ortega RP. Science. 2023;379:870-873.

Implicit biases can degrade decision making as they impact heuristics, test result interpretation, and patient/physician communication. This article highlights efforts to understand implicit biases in health care professionals. It discusses initiatives and tools in development to reduce the presence of unconscious bias in health care.

Using A.I. to detect breast cancer that doctors miss.

Save to Library

Satariano A, Metz C. New York Times. March 5, 2023.

Artificial intelligence (AI) is an innovation that represents great promise for diagnostic accuracy and timeliness improvement. This article discusses a successful AI breast cancer screening program in Hungary and its potential to illuminate efforts to spread AI-enhanced diagnosis as a tool for physician decision making.

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.

Examples of Medical Device Misconnections.

Save to Library

Food and Drug Administration. February 23. 2023.

Mismatches of medical device connectors are known factors in therapeutic agent administration failures, despite efforts to redesign equipment and minimize their occurrence. This series of case studies drawn from reports submitted to the Food and Drug Administration illustrates a variety of misconnection scenarios to demonstrate situations that have a range of potential for patient harm.

NHS staff cried in safety interviews, says watchdog.

Save to Library

Reed J. BBC. February 27, 2023.

Stressful and caustic work environments are known to compromise health care safety and teamwork. This news story discusses an ongoing investigation in the British National Health Service to examine factors in ambulance services that minimize its safety and effectiveness. Clinicians interviewed revealed serious problems with the work cultures.

Crisis in the Lakeshore Hospital ER.

Save to Library

Derfel A. Montreal Gazette. February 24- March 1, 2023

Emergency room failures are often rooted in system weaknesses. This series examines six patient deaths associated with emergency care that, while concerns were raised by nursing staff, have not been explored to initiate improvements at the facility. Factors contributing to the deaths discussed include nurse shortages, inconsistent oversight, and poor training.

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

Save to Library

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.

Maternal and Infant Health Inequality: New Evidence from Linked Administrative Data.

Save to Library

Kennedy-Moulton K, Miller S, Persson P, et al. Cambridge, MA: National Bureau of Economic Research; 2022. NBER Working Paper No. 30693.

Unequal maternal care access and safety are known problems in communities of color. This report examines the alignment of economic stability with maternal and infant care quality and found parental income secondary to race and ethnicity as a damaging influence on care outcomes.

'They were his best shot. And they failed to help’: why did EMS workers neglect Tyre Nichols?

Save to Library

Renault M. STAT. February 6, 2023.

Emergent care situations are vulnerable to a range of factors that reduce care safety and access. This article examines safety culture, implicit biases, and system issues that impacted access to needed emergency care for a patient involved in a police action.

In Conversation with Connor Wesley, RN, BSN on Patient Safety Concerns and the LGBTQ+ Population

Save to Library

Perspective on Safety February 1, 2023

Connor Wesley, RN, BSN, is a registered nurse in Tacoma, WA. In addition to his role as the Assistant Nurse Manager of the Emergency Department at MultiCare Allenmore Hospital, Connor lectures locally and nationally on providing healthcare to members of the lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ+) community. We interviewed Connor to discuss patient safety and the LGBTQ+ community.

A deadly epidural, delivered by a doctor with a history of mistakes.

Save to Library

Goldstein J. New York Times. January 23, 2023.

Active errors are evident when they occur, yet systemic weaknesses, if not addressed, allow them to repeat. This story examines poor epidural methods of one clinician that coincided with lack of organizational practitioner monitoring, unequitable maternal care for black women and clinician COVID fatigue to contribute to patient death.

Patient Safety Concerns and the LGBTQ+ Population

Save to Library

Perspective on Safety February 1, 2023

This piece discusses patient safety concerns among members of the LGBTQ+ community which may inhibit access to needed healthcare and potential ways to provide patient-centered care and mitigate the risk of adverse events.

Better off at home--how we fail children with complex medical conditions.

Save to Library

Newcomer CA. N Engl J Med. 2023;388:198-200.

Children with complex care needs present unique challenges for both parents and clinical teams. This commentary offers a physician-parent’s perspective on weaknesses in the care system that decreased medication safety for her child and also decreased patient-centeredness, including lack of a respect for the family as care team members.

Bleeding and in pain, a pregnant woman in Louisiana couldn’t get answers.

Save to Library

Westwood R. Kaiser Health News. January 12, 2023.

Lack of access to obstetric care impedes safe treatment for mothers. This story describes challenges one mother experienced in finding care during a miscarriage due to abortion policies and the steps she and her family took to manage her condition.

ER doctors misdiagnose patients with unusual symptoms.

Save to Library

Abelson R. New York Times. December 15, 2022.

Emergency department safety is challenged by factors such as production pressure, burnout, and overcrowding. This news article provides context for the 2022 AHRQ report Diagnostic Errors in the Emergency Department: A Systematic Review from the Johns Hopkins Medicine Evidence-based Practice Center (EPC) which synthesized the number of patients harmed while seeking emergency care.

The PSNet Collection: All Content

Search All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

The PSNet Collection: All Content

Search All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Case

Continue as a Guest

Continue Logged In

Submit Your Case

Continue as a Guest

Already have a PSNet

Account?

New Users