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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 177 Results
Ledlie S, Gomes T, Dolovich L, et al. Explor Res Clin Soc Pharm. 2023;9:100218.
Mandatory error reporting systems can help identify types, causes, and solutions to medication-related errors. More than 30,000 medication-related incidents were reported by community pharmacists to the Assurance and Improvement in Medication (AIMS) Program in Canada. Event type, severity, medication class, and method of detection are described. Only 60% of pharmacies submitted at least one report, indicating compliance with and participation in the AIMS Program remains low.
Curated Libraries
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.

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.
Brummell Z, Braun D, Hussein Z, et al. BMJ Open Qual. 2023;12:e002092.
Reporting adverse events and lessons learned can help improve patient safety beyond the original impacted facility, but low-quality reports can hinder learning. This study describes the quality of reports submitted during the first three years of England’s mandatory Learning from Deaths (LfD) program. While up to half of National Health Service (NHS) hospital trusts submitted data for all six regulatory statutes, a small minority did not submit any data. Three years in, the identification, reporting, and investigation of deaths has improved, but evidence of improved patient safety is still lacking.
Brummell Z, Braun D, Hussein Z, et al. BMJ Open Qual. 2023;12:e002093.
In 2017, England’s National Health Service (NHS) implemented the Learning from Deaths program which requires NHS Secondary Care Trusts (NSCT) to report, investigate, and learn from potentially preventable deaths. This study focuses on what NCSTs learned during the first three years of the program, the actions taken in response and their impact, and engagement with Learning from Deaths. Trusts appear to have varied understanding and use of the term ‘learning’ and not all specified the impact their actions had on patient safety.
Kramer DB, Yeh RW. JAMA. 2023;329:136-143.
The Food and Drug Administration (FDA) plays an important role in ensuring the safety of medical devices. In this cross-sectional study, researchers identified a high risk of future Class 1 FDA recall (the most serious recall designation, indicating serious risks to patient safety) among previously authorized devices (predicates) with prior Class 1 recalls.

HR 9377, 117th Cong, 2d Sess (2022).

The need for a national government-led patient safety effort has long been advocated for. This legislation outlines the structure of a federal agency to provide support for patient safety data collection, national incident analysis, and recommendation development.
Perspective on Safety December 14, 2022

We spoke to Dr. Michelle Schreiber about measuring patient safety, the CMS National Quality Strategy, and the future of measurement. Michelle Schreiber, MD, is the Deputy Director of the Center for Clinical Standards and Quality and the Director of the Quality Measurement and Value-Based Incentives Group at the Centers for Medicare & Medicaid Services.

Perspective on Safety December 14, 2022

This collaborative piece with the Centers for Medicare & Medicaid Services discusses the current state of patient safety measurement, advancements in measuring patient safety, and explores future directions.

Washington, DC: Veterans Affairs Office of Inspector General; 2022. Report No. 22-00818-03.

Organizational evaluations often reveal opportunities to address persistent quality and safety issues. This extensive inspection report shares findings from examinations at 45 Veterans Health Administration care facilities that focused on assessing oversight, system redesign and surgical programs. Recommendations drawn from the analysis call for improvements in protected peer review, surgical work structure and surgical adverse incident examination.

Kirkup B. Department of Health and Social Care. London, England: Crown Copyright; 2022.  ISBN: 9781528636759.

Maternity care is beset with challenges that reduce safety. This analysis provided insights into improving maternity care in the British National Health Service (NHS) focusing on the need for identification of inadequate performance, enhanced sympathetic care, common purpose in teams, honest response to difficulties and effective outcome measurement.
Friebel R, Maynou L. Health Aff (Millwood). 2022;41:1486-1495.
Patients with developmental disabilities may be at higher risk for patient safety events in hospitals. This study used data from the Learning from Lives and Deaths (LeDeR) program in the UK to examine the prevalence of five avoidable in-hospital safety events. Compared to the general populations, patients with developmental disabilities experienced more patient safety incidents, longer length of stay and increased risk of death. Although the data did not include the causes of the incidents, the results support improving both inpatient and community care for persons with developmental disabilities.
Barclay ME. JAMA Health Forum. 2022;3:e221006.
The Centers for Medicare & Medicaid Services (CMS) provides individual and composite quality and safety ratings (i.e., star ratings) for hospitals and other healthcare facilities on its Care Compare website. This study evaluated three alternative methods for rating facilities and compared them to the CMS star ratings. Hospitals were frequently assigned a different star rating using the alternate methods, typically between adjacent star categories.
Kaplan HJ, Spiera ZC, Feldman DL, et al. J Am Coll Surg. 2022;235:494-499.
Unintentionally retained surgical items (RSI) can have a devastating impact on patient health and safety. One method to reduce the incidence of RSI is radiofrequency (RF) detection. Nearly one million operations in New York state were analyzed for the rate of RSI before and after the use of RF was required and simultaneous TeamSTEPPS training was provided. The incidence of RF-detectable items was significantly reduced, but the rate of non-RF-detectable items was not.

London, England: NHS England; August 2022.

Effective response to medical error requires a comprehensive systemic and process-focused incident examination approach to ensure organizational learning. This framework will replace the current method used by the UK National Health Service (NHS) to support overarching patient safety strategic aims for the agency.
Chen Z, Gleason LJ, Sanghavi P. Med Care. 2022;60:775-783.
All nursing homes certified by the Centers for Medicaid & Medicare Services (CMS) are required to submit select patient safety data which is used to calculate quality ratings. This study compared seven years of self-reported pressure ulcer data with claims-based data for pressure ulcer-related hospital admissions. Similar to earlier research on self-reported falls data, correlations between the self-reported and claims-based data was poor. The authors suggest alternate methods of data collection may provide the public with more accurate patient safety information.
Chang ET, Newberry S, Rubenstein LV, et al. JAMA Network Open. 2022;5:e2224938.
Patients with chronic or complex healthcare needs are at increased risk of adverse events such as rehospitalization. This paper describes the development of quality measures to assess the safety and quality of primary care for patients with complex care needs at high risk of hospitalization or death. The expert panel proposed three categories (assessment, management, features of healthcare), 15 domains, and 49 concepts.
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 and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2021 report summarizes information about 508 adverse events that were reported, representing a significant increase in the year covered. Earlier reports document a fairly consistent count of adverse events. The rise reflected here is likely due to demands on staffing and care processes associated with COVID-19. Pressure ulcers and fall-related injuries were the most common incidents documented. Reports from previous years are available.

Lockhart B, Mascie-Taylor H. Crown Copyright: London, England; June 2022.  ISBN 9781912313631.

Misdiagnosis of neurological conditions, such as stroke, can lead to delays in treatment and patient morbidity and mortality. This report outlines findings from an inquiry into one misdiagnosis attributed to one neurologist in Ireland and discusses the leadership, system, process, and communication failures which permitted misdiagnoses to go unchecked.
Kepner S, Adkins JA, Jones RM. Patient Safety. 2022;4:6-17.
Residents at long-term care facilities are at increased risk for healthcare-associated infections. Using 2021 data from the Pennsylvania Patient Safety Reporting System (PA-PRS), this study characterized healthcare-associated infections (HAIs) occurring at long-term care facilities. Researchers found that HAIs occurring at long-term care facilities decreased, but it is unknown whether this is reflective of fewer infections or poor reporting practices at long-term care facilities, or both.