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 221 Results

Alliance for Innovation on Maternal Health: Consensus Bundle on Sepsis in Obstetric Care.

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Bauer ME, Albright C, Prabhu M, et al. Obstet Gynecol. 2023;142:481-492.

Reducing maternal morbidity and mortality is a critical patient safety priority. Developed by the Alliance for Innovation on Maternal Health (AIM), this patient safety bundle provides guidance for healthcare teams to improve the prevention, recognition, and treatment of infections and sepsis among pregnant and postpartum patients.

Understanding and Improving Diagnostic Safety in Ambulatory Care.

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Rockville, MD: Agency for Healthcare Quality and Research; August 22, 2023.

The articulation of diagnostic error in the ambulatory setting is emerging. These newly released funding announcements seek proposals that focus on understanding the factors contributing to diagnostic error and strategies to improve diagnostic safety in the ambulatory care environment. The application deadline for both opportunities has passed.

‘The Retrievals’ reveals painful experiences of female patients are often ignored.

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Desjardins L. PBS NewsHour. August 29, 2023.

Disregard for women’s pain is a persistent problem in health care. This news segment discusses a podcast highlighting a pattern of dismissal of patient concerns that resulted in harm and allowed fentanyl diversion by a nurse with substance abuse disorder to go undetected.

The e-Autopsy/e-Biopsy: A Systematic Chart Review to Increase Safety and Diagnostic Accuracy Innovation

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Patient Safety Innovation August 30, 2023

Addressing diagnostic errors to improve outcomes and patient safety has long been a problem in the US healthcare system.¹ Many methods of reducing diagnostic error focus on individual factors and single cases, instead of focusing on the contribution of system factors or looking at diagnostic errors across a disease or clinical condition. Instead of addressing individual cases, KP sought to improve the disease diagnosis process and systems. The goal was to address the systemic root cause issues in systems that lead to diagnostic errors.

Quality and safety practices among academic obstetrics and gynecology departments.

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Christopher D, Leininger WM, Beaty L, et al. Am J Med Qual. 2023;38:165-173.

Staff engagement in safety and quality improvement efforts fosters a culture of safety and can reduce medical errors. This survey of 52 obstetrics and gynecology departments at academic medical centers found that few departments provided faculty with protected time or financial support for quality improvement activities, and only 5% of departments included a patient representative on the quality committee.

Toolkits To Reduce Hypertension in Pregnancy and Obstetric Hemorrhage.

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

Obstetric hemorrhage and severe high blood pressure during pregnancy are leading known causes of preventable maternal harms in the United States. The AHRQ Safety Program for Perinatal Care, Phase 2 developed toolkits consisting of case scenarios, slides, and facilitators guides to work in tandem to address these threats to maternal safety. The materials inform training opportunities to improve the safety culture of labor and delivery units and decrease maternal and neonatal adverse events that result from poor communication and system failures.

The Retrievals.

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Burton S. New York Times and Serial Productions. June 30-July 27, 2023.

Unnoticed drug diversion can result in harm to patients, clinicians, and organizations. This series describes how diversion contributed to unnecessary pain in fertility clinic patients. The problem was compounded by a lack of attention to women voicing their concerns about procedural pain.

Advancing Diagnostic Excellence in Maternal Health Care.

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Board on Health Care Services, National Academies of Science, Engineering, and Medicine. Irvine, CA: Arnold and Mabel Beckman Center: 2021-2023.

These free workshops discussed current challenges in diagnostic excellence, identifications of knowledge gaps, and strategies to decrease maternal disparities, cancer misdiagnoses and problems in the care of older adults that affect diagnosis.

Causes for medical errors in obstetrics and gynaecology.

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Klemann D, Rijkx M, Mertens H, et al. Healthcare (Basel). 2023;11:1636.

Reducing maternal morbidity and mortality is a global patient safety goal. This systematic review identified three categories of direct and indirect risk factors of maternal safety: delay of care, coordination and management of care, and scarcity of supply, personnel, and knowledge. The risk factors varied between developed and developing countries.

Care Post-Roe: Documenting Cases of Poor-quality Care Since the Dobbs Decision.

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Grossman D, Joffe C, Kaller S, et al. Advancing New Standards in Reproductive Health, University of California, San Francisco; 2023.

Overarching policy decisions have the potential to impact systems of care and harm patients. This document reports the preliminary findings of a study examining 50 cases submitted where clinicians modified care standards in response to abortion access limitations. The changes affected the timeliness, quality, safety, cost, and complexity of care delivered to pregnant patients.

Why do so many Black women die in pregnancy? One reason: doctors don't take them seriously.

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Stafford K. AP News. May 23, 2023.

Racial inequities and implicit bias undermine safe maternal care. This article highlights the potential for maternal sepsis in the Black patient population and the role structural racism plays in this situation. The article is a part of the 2023 “Birth to Death" article series.

Racial and ethnic disparities in obstetric and gynecologic care and role of implicit biases.

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Bryant A. UpToDate. May 18, 2023.

Implicit bias is progressively being discussed as a detractor to safe health care by fostering racial and ethnic inequities. This review examines the history of health inequities at the patient, provider, health care system, and cultural levels in obstetric and gynecologic care. It shares actions documented in the evidence base for application in health care to reduce the impact of implicit bias, with an eye toward maternal care

The time is now: addressing implicit bias in obstetrics and gynecology education.

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Royce CS, Morgan HK, Baecher-Lind L, et al. Am J Obstet Gynecol. 2023;228:369-381.

Racism and implicit biases can threaten the safety of care. The authors in this article outline how implicit bias can affect health professional trainees and impact patient care in obstetrics and gynecology, and outlines strategies to address implicit bias through bias awareness and management curricula, ensuring a supportive learning environment, and faculty development.

Saving Moms.

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Boswell B. KCET: April 2023.

Increasing attention is being placed on addressing inequities in maternal health care. This video shares stories of mothers experiencing harm during pregnancy and steps being taken to minimize the impact of implicit biases and lack of access to care to generate improvement.

Mothers face broken addiction treatment system.

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D'Ambrosio A. MedPage Today. March 31, 2023.

Maternal health is challenged across social strata but notably amongst populations of color, economic disparity, and social minority. This article discusses barriers mothers face trying to manage substance use disorders during pregnancy and after birth due to system problems and stigma.

Addressing Medical Gaslighting to Improve Maternal Health—Together.

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Oregon Patient Safety Commission: 2023.

Gaslighting has been identified as a contributor to maternal mortality and morbidity. This toolkit of compiled resources aims to help inform organizational activities to establish programs and strategies to reduce the impact of disrespect, implicit bias and inequities that affect the care of pregnant persons.

Pilot implementation of a health equity checklist to improve the identification of equity-related adverse events.

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Patient Safety Innovation March 29, 2023

Minoritized patients continue to experience disproportionately high rates of maternal morbidity and mortality. This hospital developed a health-equity checklist to identify if bias and/or social determinants of health played a role in preventable adverse events.

Recognizing our biases, understanding the evidence, and responding equitably: application of the socioecological model to reduce racial disparities in the NICU.

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McCarty DB. Adv Neonatal Care. 2023;23:31-39.

Racism is increasingly seen as a major contributor to poor maternal care and adverse outcomes. This article summarizes racial health disparities impacting patients in the neonatal intensive care unit (NICU) and interventions to reduce racial bias in the NICU.

The (commercialised) experience of operating: embodied preferences, ambiguous variations and explaining widespread patient harm.

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Ducey A, Donoso C, Ross S, et al. Sociol Health Illn. 2023;45:346-365.

Research has identified variations in treatment that are unlikely to be related to patient characteristics, such as region. In this study, surgeons describe their preferences for and experiences with a device which caused widespread harm to women and was ultimately recalled by several patient safety agencies: transvaginal mesh for the treatment of pelvic floor devices in women. Even when surgeons arrived at the same decision (to perform surgery or not), wide variations were observed during the decision-making process.

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

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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.

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