Skip to main content

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

Search Tips
Save
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Search By Author(s)
Additional Filters
Approach to Improving Safety
Clinical Area
Safety Target
Displaying 1 - 20 of 1819 Results

World Health Organization.

The sharing of best practices is a key component of enabling successful strategy implementation in support of patient safety plans and goals. This website will capture, organize, and share experiences worldwide to support knowledge sharing and community building to reduce World Patient Safety Day targeted challenges.

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

Patient safety progress is dynamic, consistently producing evidence for application to generate improvements. This report is the fourth in a series funded by the Agency for Healthcare Research and Quality to track a prioritized set of emerging and existing safety approaches to confirm their value and effectiveness. This report will be compiled as new conclusions are formulated. Each review will be posted to the collection as they are completed. The first three Making Healthcare Safer reports, published in 2001, 2013, and 2020, have each served as a consolidated evidence source for clinicians, health system leadership, researchers, and government agencies. Chapter protocols and the results of an examination of harms associated with video-based telehealth are now available. 
Yartsev A, Yang F. Simul Healthc. 2023;18:279-282.
Intensive care units (ICUs) are complex care environments at high risk for medical errors. In this retrospective study, researchers identified the occurrence of common ICU scenarios and skills during code blue events and measured trainees’ self-reported confidence in these skills. The analysis found that more than 25% of trainees reported low levels of confidence in three scenarios – familiarity with the advanced life support trolley, electrocardiogram strip interpretation, and operation of an external defibrillator. This process of integrating critical incident data with trainee self-assessment can be generalized to other clinical scenarios to create targeted education and simulation curriculum.
San José-Saras D, Vicente-Guijarro J, Sousa P, et al. BMC Med. 2023;21:312.
Inappropriate care, such as under- or over-treatment or unnecessary hospitalizations, can place patients at risk for adverse events. This observational study set in a high-complexity hospital in Spain found that patients with inappropriate hospital admissions (IHA) have a higher risk of subsequent adverse events, contributing to longer stays and additional costs.
McGurgan P. Aust N Z J Obstet Gynaecol. 2023;63:606-611.
Individual-, team-, and systems-based factors can affect safety during childbirth. This article discusses several patient safety threats that can hinder the safety of vaginal birth after cesarean (VAC) deliveries in high population density areas, including staffing and resource limitations, cultural and human factors, and patient communication.

Stratford, London; The National Guardian.

Organizational efforts to collect and respond to the concerns of staff and patients are a cornerstone to patient safety improvement despite challenges to implement them. This annual report presents insights drawn from problems staff share with Freedom to Speak Up Guardians in the United Kingdom to capitalize on problems to drive improvement. The 2023 report summarized data collected from over 25,000 cases recorded.
Perspective on Safety August 30, 2023

This piece focuses on the importance of patient safety following the end of the public health emergency and how organizations can move beyond the pandemic.

This piece focuses on the importance of patient safety following the end of the public health emergency and how organizations can move beyond the pandemic.

Patricia McGaffigan

This piece focuses on the importance of patient safety following the end of the public health emergency and how organizations can move beyond the pandemic.

Baimas-George MR, Ross SW, Yang H, et al. Ann Surg. 2023;278:e614-e619.
Hospital-acquired venous thromboembolism (VTE) remains a significant source of preventable patient harm. This study of 4,252 high-risk general surgery patients found that only one-third received care in compliance with VTE prophylaxis guidelines. Patients receiving guideline-compliant care experienced shorter lengths of stay (LOS), fewer blood transfusions, and decreased odds of having a VTE, emphasizing the importance of initiating VTE chemoprophylaxis in high-risk general surgery patients.
Tripathi S, McGarvey J, Lee K, et al. Pediatrics. 2023;152:e2022059688.
Reducing central line-associated bloodstream infections (CLABSI) is an important patient safety improvement target. This study examined the relationship between compliance with evidence-based CLABSI guideline bundles and CLABSI rates in 159 hospitals. Between 2011 and 2021, researchers found that adherence to bundle guidelines was associated with a significant reduction in CLABSI rate.

Washington, DC: United States Government Accounting Office; July 10, 2023.  Publication GAO-23-105722.

Health information systems are fundamental tools for documenting adverse event trends within and across patient populations. This report highlights weaknesses in the web-based incident reporting system employed to track quality of care for American Indians and Alaska Natives. Recommendations for improvement focus on increasing leadership engagement and use of the data collected to examine instances of patient harm or near misses in the American Indians and Alaska Native patient population.

Waldman A. ProPublica. August 9, 2023

Systemic failures can enable poor practice to perpetuate without regard to safety. This news feature reports on systemic flaws that enabled a vascular surgeon with questionable business and clinical skills to continue to practice after numerous regulatory organizations investigated his clinics, and after patients reported harm.
Alanazi FK, Lapkin S, Molloy L, et al. Intensive Crit Care Nurs. 2023;78:103480.
Safety culture, nurses' safety attitudes, and staffing ratios have been shown to impact fall rates and other healthcare associated events. This study assessed if healthcare-associated infections (HAIs) could be associated with nurses' safety attitudes and other quality and safety metrics in the intensive care unit (ICU). Increased job satisfaction was associated with lower rates of HAI, as were lower rates of missed care. The study also found nurses' perceptions and actual incidence of two HAI were positively correlated, suggesting nurses can provide valuable information on HAIs and HAI reduction efforts.
Hibbert PD, Molloy CJ, Schultz TJ, et al. Int J Qual Health Care. 2023;35:mzad056.
Accurate and reliable detection and measurement of adverse events remains challenging. This systematic review examined the difference in adverse events detected using the Global Trigger Tool compared to those detected via incident reporting systems. In 12 of the 14 included studies, less than 10% of adverse events detected using the Global Trigger Tool were also found in corresponding incident reporting systems. The authors of the review emphasize the importance of using multiple approaches and sources of patient safety data to enhance adverse event detection.
Weaver MD, Sullivan JP, Landrigan CP, et al. Jt Comm J Qual Patient Saf. 2023;Epub Jul 7.
The Accreditation Council for Graduate Medical Education (ACGME) restrictions on resident work hours have improved resident well-being, but the impact on education, clinical and patient safety outcomes is less clear. This meta-analysis found that the 2003 ACGME restrictions (limiting residents to 80-hour work weeks and 28-hour shifts) was associated with an 11% reduction in mortality; however, there was no significant difference in mortality after the 2011 restrictions (limiting first-year residents to 16-hour shifts). These findings reinforce the impact of extended resident physician work hours and patient morbidity and mortality. The authors also recommend that future research examine the relationship between work hours and patient outcomes among other health care workers.
Duhalde H, Bjuresäter K, Karlsson I, et al. Int Emerg Nurs. 2023;69:101296.
Missed nursing care (MNC) refers to needed nursing care that is delayed, partially completed, or not completed at all, and can result in adverse events. This systematic review summarizes missed nursing care in emergency departments (ED). Causes of MNC include overcrowding and patients with complex care needs, which may result in medication errors, pressure injuries, or patient deterioration.
Zińczuk A, Rorat M, Simon K, et al. Viruses. 2023;15:1430.
The COVID-19 pandemic exacerbated many existing patient safety challenges. This retrospective analysis of 477 fatal COVID-19 cases at one hospital in Poland found that one-third of patients experienced a healthcare-acquired infection during their hospitalization as well as other hospital-acquired complications, including thrombolytic and/or bleeding complications, acute kidney injury, and exacerbation of chronic heart disease. The analysis also found that many patients experienced delays in specialist treatment (33%) or lack of specialist treatment (17%) during their hospitalization.
Lyren A, Haines E, Fanta M, et al. BMJ Qual Saf. 2023;Epub Jul 17.
Previous research has found that racial and ethnic disparities can hinder the safe care of pediatric patients. In this cross-sectional study, researchers examined racial and ethnic disparities in central line-associated bloodstream infection (CLABSI) and unplanned extubation (UE) rates across 27 children’s hospitals in the United States. Compared to White patients, Black and African-American patients had higher UE rates and Hispanic, Native American, and Pacific Islander patients had higher CLABSI rates.

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.

Salamon M. Harvard Women's Health Watch. August 1, 2023

Patients can help minimize the potential for adverse events while in the hospital. Actions such as working with a care partner, tracking medications, and recognizing fall risks can protect against mistakes causing harm.