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 383 Results

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 will close January 25, 2023.

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 SA, 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.

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.

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.

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. HSIB Report no. NI-005831

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.

Maternal Health Research Centers of Excellence (U54 Clinical Trial Optional).

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National Institutes of Health. August 11, 2022. RFA-HD-23-035.

Maternity care is increasingly being recognized as vulnerable to implicit biases and social inequities. This funding announcement aims to support initiatives that promote equity as a primary component of efforts to study preventable maternal harm in a variety of disadvantaged and ethnic populations. The application process is now closed.

Mark Graber Diagnostic Quality & Safety Award.

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Society to Improve Diagnosis in Medicine.

Inspired by the work and leadership of Dr. Mark Graber, this award will annually recognize either lifetime achievements or stand-alone innovations that enhance efforts to improve the safety and quality of diagnosis. The process for submitting a 2022 nomination is closed.

Hospitals will still have to share safety data publicly—CMS will publish scorecard of avoidable patient harm after all.

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Clark C. MedPage Today. August 4.

Consistent policy supporting transparency of hospital safety records is important for patients as they make provider choices. This article highlights a shift made to retain reporting requirements in the Hospital-Acquired Condition Reduction Program (HACRP) that had been threatened due to the influence of the COVID pandemic on data integrity.

Combined impact of Medicare's hospital pay for performance programs on quality and safety outcomes is mixed.

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Waters TM, Burns N, Kaplan CM, et al. BMC Health Serv Res. 2022;22:958.

Pay-for-performance (P4P) strategies have been used by federal agencies to incentivize high quality care and reduce medical errors. This study used 2007 to 2016 inpatient discharge data from 14 states to compare rates of inpatient quality indicators and patient safety indicators before and after the implementation of the Medicare’s P4P program. Analyses identified limited improvement in quality and patient safety indicators.

Examining the Status of VA’s Electronic Health Record Modernization Program.

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US Senate Committee on Veterans Affairs. 117th Cong (2021-2022). (July 20, 2022).

Large-scale electronic health record (EHR) implementation projects encompass a myriad of problems to navigate to arrive at success. This Congressional panel explores challenges experienced during EHR implementation in the VA Health system. Panelists from the Veterans Administration, the investigator and the technology vendor involved in the program shared insights and next steps to direct improvement.

The 2021 John M. Eisenberg Patient Safety and Quality Awards.

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Jt Comm J Qual Patient Saf. 2022;365-387.

The memory of John Eisenberg, MD, continues to motivate patient safety improvement. The 2021 honorees for the award presented in Dr Eisenberg’s honor are Hardeep Singh, MD, MPH, Prime Healthcare Services, Ontario, California, Kaiser Permanente Northern California, Oakland, California, and Mark R. Chassin, MD, FACP, MPP, MPH.

John M. Eisenberg Patient Safety and Quality Award.

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Joint Commission, National Quality Forum.

The Eisenberg Award honors individuals and organizations who have made key contributions to patient safety and quality improvement. The awards are presented at the National Quality Forum's annual policy conference in Washington, DC. This website provides information on all the recipients and the application process. The process for submitting an application for the 2023 award cycle will open in the summer.

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