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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 377 Results

Agency for Healthcare Research and Quality.

Telemedicine efforts harbor both risk and reward to patients and providers. The AHRQ Safety Program for Telemedicine is a national effort to develop and implement a bundle of evidence-based interventions designed to improve telemedicine care in two settings—the cancer diagnostic process and antibiotic use. To test the bundle of interventions, the program will involve two cohorts of healthcare professionals who utilize telemedicine as a care delivery model. It is an 18-month program, beginning in June 2023, that seeks to improve the cancer diagnostic process for patients who receive some or all of their care through telemedicine. Recruitment webinars start in late January and run through early May 2023; the antibiotic use cohort will begin recruitment in December 2023. 
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. 

Boston, MA; Institute for Healthcare Improvement: December 2022.

Systemic efforts to improve health equity support patient safety. This announcement highlights an initiative for collective work to address four areas of effort to reduce inequity in health care: access, workforce, social and structural drivers, and quality and safety.

Healthcare Excellence Canada. 2022.

After a patient safety incident, effective discussions are critical for healing and improvement. This website houses collections of materials to support constructive communication should a failure or near-miss occur. There are two distinct sections of materials: one for established healthcare professionals, and another for patients, students, and caregivers.
The Joint Commission.
The National Patient Safety Goals (NPSGs) are one of the major methods by which The Joint Commission establishes standards for ensuring patient safety in all health care settings. In order to ensure health care facilities focus on preventing major sources of patient harm, The Joint Commission regularly revises the NPSGs based on their impact, cost, and effectiveness. Major focus areas include promoting surgical safety and preventing hospital-acquired infections, medication errors, inpatient suicide, and specific clinical harms such as falls and pressure ulcers. The 2023 goals are now available.
Leapfrog Group
Drawing from data reported by the Leapfrog Hospital Survey, the Agency for Healthcare Research and Quality (AHRQ), the Centers for Disease Control and Prevention (CDC), and the Centers for Medicare and Medicaid Services (CMS), this website provides grades for hospitals in the United States based on their safety. The Fall 2022 hospital safety grade results, representing the 10th anniversary of the program, are available. A 2019 report from the Armstrong Institute examines avoidable death associated with grading hospitals. 
Premier House, 60 Caversham Road, Reading, RG1 7EB.
Independent investigations examine system weaknesses in health care to inform improvement, reduce risk, and prevent harm. This organization collects information from individuals, groups, and organizations to identify and analyze incidents of substandard care and to proactively provide recommendations to reduce conditions that perpetuate failure in the National Health Service. Investigation areas include medication delivery for older patients and safe maternity care.

US Department of Health and Human Services.

The large system change required to reduce patient harm requires multi-stakeholder engagement and sustained commitment. This alliance will work with healthcare systems, federal partners, patients and families, and other stakeholders to implement a national plan to ensure the safety of patients and healthcare workers. The webinar introducing the program, featuring Department of Health and Human Services Secretary Xavier Becerra, was held November 14, 2022.
Newcastle Upon Tyne, UK: Care Quality Commission; October 2022.
This website provides access to an annual report that summarizes National Health Service hospital and social care performance across a range of care quality metrics at both the trust and service level. The 2022 report found most facilities to be generally operating at a effective level and basic performance was found to be high. However the report found substantial gaps in specialties such as maternity care and recognized staffing challenges that impact access and quality.
World Health Organization. September 17, 2022.
Patients, families, and providers around the world are affected by medical error. This annual event and its associated materials seek to raise awareness, motivate collaboration, and stimulate innovative work targeting a distinct patient safety theme. The 2022 theme is “Medication Safety” with the slogan “Medication without Harm". Explicit objectives of the effort include increasing awareness worldwide of the impact of medication errors and enabling a robust patient and family role in medication safety efforts.
Institute for Safe Medication Practices; 5200 Butler Pike, Plymouth Meeting, PA 19462.
This redesigned Web site provides information about drug safety alerts and allows consumers to help report and prevent medication errors.

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.
Healthcare Excellence Canada.
This site provides promotional materials for an annual awareness campaign on patient safety that takes place in the autumn. The annual observance is held in late October.
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.
Agency for Healthcare Research and Quality
The AHRQ Patient Safety Indicators (PSIs) represent quality measures that make use of a hospital's available administrative data. The PSIs reflect the quality of inpatient care but also focus on preventable complications and iatrogenic events. Investigators have found PSIs to be a useful tool for understanding adverse events and identifying possible areas of improvement within health care delivery systems. Although relying on administrative data has clear limitations, select PSIs have been shown to accurately identify certain accidental inpatient injuries. The AHRQ Web site offers publicly available comparative data, along with resources and tools. Patient safety measurement methods are discussed in an AHRQ WebM&M perspective. Originally released in 2005, the PSI were most recently updated in July 2022.

University of California San Francisco, San Francisco, CA.

Systemic racism reduces the effectiveness and safety of the care people of color receive. The REPAIR (REParations and Anti-Institutional Racism) Project is examining the impact of racism on Black individuals in medicine and the sciences. Each year of the 3-year initiative is focused on a distinct theme: medical reparations, medical abolitionism and decolonizing the health sciences.

Agency for Healthcare Research and Quality. 

Effective measurement of diagnostic error is essential for understanding the problem and generating improvements. The Common Formats provide a standard terminology for voluntary reporting of diagnostic errors to patient safety organizations. This website provides access to tools supporting use of the Common Formats that include forms and a users' guide.
Rockville MD: Agency for Healthcare Research and Quality; 2020.
Culture has been described as a key to establishing high reliability organizations. The National Quality Forum's Safe Practices for Healthcare and the Leapfrog Group both mandate hospitals to regularly assess their safety culture. This AHRQ Web site provides validated safety culture survey tools (Hospital, Medical Office, Nursing Home, Community Pharmacy, Ambulatory Surgery Center) and user guides health care organizations can use to implement the surveys. Organizations can also use the AHRQ database to compare their Surveys on Patient Safety Culture™ (SOPS®) results. In addition, reports are available that summarize the benchmarking data across cohorts nationwide. An AHRQ WebM&M perspective discussed how to establish a safety culture.
Society for Simulation in Healthcare.
Simulation provides a safe space to observe behaviors and generate constructive feedback to enhance individual and team performance. This website provides promotional materials for an annual campaign to raise awareness of professionals that use simulation to develop teamwork, communication, and crisis management skills in health care. The 2022 observance will be held September 12-16.

National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health; Centers for Disease Control and Prevention. 

Maternal harm during and after pregnancy is a sentinel event. This campaign encourages women, families, and health providers to identify and speak up with concerns about maternal care and act on them. The program seeks to inform the design of support systems and tool development that enhance maternal safety.