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 379 Results

Potential costs and consequences associated with medication error at hospital discharge: an expert judgement study.

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Kirwan G, O’Leary A, Walsh C, et al. Eur J Hosp Pharm. 2023;30:86-91.

Patients are particularly vulnerable to medication errors during transitions of care, such as hospital discharge. Based on clinical judgement from four experts assessing 81 cases involving medication errors at discharge, the authors estimated that between 61-85% would result in additional healthcare utilization (e.g., additional prescriptions, primary care or ED visits, hospital or ICU admissions) and additional costs.

VA pauses $16B Oracle Cerner EHR deployments indefinitely to address error-ridden early rollout.

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Muoio D. Fierce Healthcare. April 21, 2023.

Notable problems have occurred during the testing of the new electronic health records (EHR) system being designed for use in Veterans Affairs hospitals. This news article discusses the temporary halt of the project as the Department reassesses issues that have arisen during test rollouts in several United States hospitals.

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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.

Understanding and Improving Diagnostic Safety in Ambulatory Care.

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Rockville, MD: Agency for Healthcare Quality and Research; February 8, 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 is April 18, 2023.

Association of past and future paid medical malpractice claims.

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Hyman DA, Lerner J, Magid DJ, et al. JAMA Health Forum. 2023;4:e225436.

Prior research has shown that physicians with more than three paid medical malpractice claims are at increased risk of another claim in the next two years. This study assessed the risk of additional claims after just one paid malpractice claim, whether public disclosure of claims increased the risk, and whether the risk changes over time. The authors also compare actual claims rates to simulated rates if malpractice claims were “random” events unrelated to prior claims.

AHRQ-Funded Patient Safety Project Highlights: Improving Healthcare Safety by Engaging Patients and Families.

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Rockville, MD: Agency for Healthcare Research and Quality; January 2023. AHRQ Pub. No.22(23)-0065-1.

Research has shown that involving patients, their families and caregivers, in the planning, delivery, and evaluation of their healthcare can improve safety and quality. This collection of AHRQ-funded work includes summaries of 53 projects since 2000 that contributed to environments in which patients, families, and healthcare professionals work together to improve the quality and safety of care. Efforts highlighted include those involving patients and families in activities designed to report and ultimately prevent medical errors and near misses.

Lewis Blackman Patient Safety Award.

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Chicago, IL: American College of Graduate Medical Education.

Lewis Blackman was a young man who lost his life to medical error when the severity of his condition after elective surgery was unrecognized by clinicians caring for him. This award will acknowledge residents and fellows engaged in developing educational programs on patient safety. Nominations for the 2024 award cycle are due March 15, 2023.

The Joint Commission and National Quality Forum Announce 2022 Eisenberg Award Recipients.

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Oakbrook Terrace, IL: Joint Commission and National Quality Forum: January 23, 2023.

The annual Eisenberg Award recognizes leaders and organizations who have made substantial contributions toward patient safety and quality improvement. The 2022 honorees are Jason S. Adelman, MD, MS, North American Partners in Anesthesia (NAPA) and Parkland Health, Dallas County, Texas. The awards will be presented at the National Quality Forum's annual conference on February 20, 2023, in Washington, DC.

Patient Safety Learning Laboratories: Advancing Patient Safety through Design, Systems Engineering, and Health Services Research (R18 Clinical Trial Optional).

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Rockville, MD: Agency for Healthcare Research and Quality. PA-21-266.

This funding opportunity will support collaborative learning strategies that enable individuals and organizations to employ rapid prototyping to engineer new approaches focused on improving diagnosis and treatment. This learning laboratory funding builds on prior initiatives to further improvements in patient safety. The project submission process is now closed.

Patient Safety Awareness Week.

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Institute for Healthcare Improvement.

This website provides resources for promoting patient safety during Patient Safety Awareness Week. The 2023 observance will be held March 12-18.

Electronic health record legal settlements in the US since the 2009 Health Information Technology for Economic and Clinical Health Act.

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Apathy NC, Howe JL, Krevat S, et al. JAMA Health Forum. 2022;3:e223872.

Electronic Health Record (EHR) systems are required to meet meaningful use and certification standards to receive incentive payments from the US Department of Health and Human Services (HHS). This study identified six settlements reached between EHR vendors and the Department of Justice for misconduct related to certification of meaningful use. Certification of EHR systems that don’t meet HHS meaningful use requirements may have implications for patient safety.

Association of measured quality and future financial performance among hospitals performing cardiac surgery.

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Enumah SJ, Sundt TM, Chang DC. J Healthc Manag. 2022;67:367-379.

Hospitals that implement quality improvement initiatives improve patient safety but also incur financial expenses related to implementation, sustainment, and reporting. This study used data from the American Hospital Association and Hospital Compare to evaluate the relationship of financial performance and quality in hospitals performing cardiac surgery. The findings indicate hospitals with lower Patient Safety Indicator 90 (PSI 90) scores had poorer financial performance in the following year.

Transparency, public reporting, and a culture of change to quality and safety in cardiac surgery.

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Ibrahim M, Szeto WY, Gutsche J, et al. Ann Thorac Surg. 2022;114:626-635.

Reports of poor care in the media or public reporting systems can serve as an impetus to overhauling hospitals or hospital units. After several unexpected deaths and a drop in several rating systems, this cardiac surgery department launched a comprehensive quality improvement review. This paper describes the major changes made in the department, including role clarity and minimizing variation in 24/7 staffing.

Medicare fines for high hospital readmissions drop, but nearly 2,300 facilities are still penalized.

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Rau J. Kaiser Health News. November 1, 2022.

The COVID-19 pandemic necessitated adjustments in activities across health care to address patient care and staffing demands. This news article discusses COVID-19’s impact on the hospital-acquired condition reduction program, and how 43 percent of US hospitals failed to reach readmission goals.

Diagnostic Safety Centers of Excellence.

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Rockville, MD: Agency for Healthcare Research and Quality; October 2022.

Diagnostic improvement engages a variety of activities to achieve excellence. This announcement highlights ten organizations AHRQ funded to establish Diagnostic Safety Centers of Excellence. Their focused efforts will work to improve diagnostic safety and quality. Areas of project focus include use of information technology to improve diagnostic accuracy and teamwork as an improvement strategy.

DAISY Award for Extraordinary Nurses in Patient Safety.

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The Daisy Foundation and Institute for Healthcare Improvement.

Nurses have a fundamental role in safe care delivery by fostering a healthy work environment. This award recognizes nurses that exhibit compassion, patient and family centeredness, and a commitment to workplace safety. The award will be presented at annual IHI Patient Safety Congress. The award nomination process is now closed.

American Hospital Association–McKesson Quest for Quality Prize.

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American Hospital Association.

This award program recognizes organization-wide commitment to five key goals that support high-quality health care: access, health, innovation, affordability, individual as partner. The deadline for submitting an application for the 2023 award cycle has passed.

Patient safety and legal regulations: a total-scale analysis of the scientific literature.

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Yeung AWK, Kletecka-Pulker M, Klager E, et al. J Patient Saf. 2022;18:e1116-e1123.

Legal and policy approaches are used to achieve sustained safety improvements. This review characterized the body of evidence regarding patient safety and its legal implications. Four approaches to improving safety were commonly covered in the literature – liability system reforms, new forms of regulation, increased transparency, and financial incentives.

Hospital-acquired conditions reduction program, racial and ethnic diversity, and Magnet designation in the United States.

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Boamah SA, Hamadi HY, Spaulding AC. J Patient Saf. 2022;18:e1090-e1095.

Medicare’s Hospital-Acquired Condition (HAC) Reduction Program financially incentivizes hospitals to reduce HAC rates and earlier research has shown hospitals in more diverse areas have higher odds of performing poorly. This study compares HAC reduction in Magnet and non-Magnet hospitals and examines potential racial and ethnic disparities. Similar to an earlier study, Magnet hospitals had significant improvements in methicillin-resistant Staphylococcus aureus (MRSA) rates, but not other HACs.

HSIB Maternity Investigation Programme Year in Review 2021/22. Summary of Highlights, Themes and Future Work.

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Farnborough, UK: Healthcare Safety Investigation Branch; 2022.

This report summarizes the work of an independent office that examines maternity care safety lapses in the United Kingdom. It discusses the number of investigations done, criteria for investigation selection and primary improvement themes drawn from the review of 706 investigations in the period covered which include clinical assessment and oversight, care escalation, and fetal monitoring. The report outlines the goal to establish a maternity review effort as an independent entity in 2023.

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