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 1520 Results

Hospitals in two states denied an abortion to a miscarrying patient. Investigators say they broke federal law.

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Surana K. Pro Publica. May 19, 2023.

The unintended clinical consequences of abortion restrictions are beginning to emerge. This article shares how one woman faced personal health risks due to clinician concerns stemming from barriers to abortion care and how the Emergency Medical Treatment & Labor Act (EMTALA) may be employed to minimize care limitations in emergent pregnancy-related situations.

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.

Smart infusion pump investigations after an unexplained over-infusion.

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ISMP Patient Safety Alert! Acute care edition. May 18, 2023;28(10);1-3.

Dose error-reduction systems (DERS) and drug libraries are tools for use with smart infusion pumps to ensure safe intravenous medication administration. This article discusses infusion problems unrelated to user error that went undetected by the technology and reached patients. Recommendations to minimize similar occurrences include removing the involved device from service and investigating the incident.

Actions to renew focus on safety culture.

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Salvon-Harman J. Healthcare Executive. 2023;39(3):48-49.

A strong safety work environment is core to reliable care delivery and staff wellbeing. This article discusses how leadership should listen broadly, embody accountability, support disclosure, and build trust to build a robust safety culture.

The impact of language barriers on patient care: a pharmacy perspective.

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Patel J. PM Healthcare Journal. Spring 2023(4):5-18.

Language discordance is known to degrade medication safety. The article discusses an examination of English pharmacists’ reactions and responses to language barriers with patients. The results highlight the need for improved training and support for pharmacists to effectively dispense medications and counsel patients with whom they don’t share a common language.

AI may be on its way to your doctor’s office, but it’s not ready to see patients.

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Tahir D. KFF Health News. May 12, 2023.

Real-time use of artificial intelligence (AI) in health care settings continues to cause concern despite its potential to improve care. This article examines current efforts to develop AI applications for health care and the reasons for oversight to protect privacy, reduce bias, and prevent misinformation.

How the opioid backlash went wrong.

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Freedman DH. Newsweek Magazine. May 12, 2023.

The unintended consequences of reductions in access to prescription opioids can result in poor addiction care and ineffective pain management. This article discusses precursors to the system failure affecting these patients and treatment options that work given access and supply constraints.

Medical errors kill thousands of people each year. But are hospitals getting any safer?

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Weintraub K. USA Today. May 3, 2023.

The semi-annual Leapfrog Hospital Safety Grades are recognized across the industry as a tool for highlighting successes and tracking gaps in safety to focus improvement efforts. This article shares one organization’s work to improve core safety activities related to medication safety, falls, infections, and hand hygiene.

Laura Levis' death outside ER has changed hospital signage, lighting in Mass.

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Mullins L, Menard F. WBUR. April 27, 2023.

Incomplete information and building design problems can reduce access to care and contribute to harm. This story outlines how the state of Massachusetts responded to the accidental death of a patient unable to get help due to poor signage and incomplete directional information while experiencing an asthma attack.

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.

Ensuring competency and safety when onboarding newly hired professional staff.

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ISMP Medication Safety Alert! Acute care edition. April 20, 2023;28(8):1-4; May 4, 2023;23(9):1-3.

Psychological safety is required for clinicians to ask questions as they adjust to working in new teams and environments. Part 1 of this article examines the cultural qualities enabling safe onboarding of new practitioners that encourage asking for assistance when uncertainty arises. Recommendations to encourage new hire questioning include mentor programs and scheduled supervisor conversations. Part 2 discusses the role of simulation to build skills in new staff to ensure medication safety.

Doctors must stop tuning out Black women. It happened to me, as a pregnant OB-GYN.

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Gillispie-Bell V. USA Today. April 14, 2023.

Structural racism and implicit biases can lead to poor quality of care and adverse outcomes among Black women. This article describes the experience of a Black OB/GYN patient whose concerns about abdominal pain during her pregnancy were not thoroughly evaluated; clinicians also missed risk factors placing her at risk of spontaneous preterm birth.

The high cost of retained surgical items.

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Moorehead LD. Outpatient Surgery. April 5, 2023.

Retained surgical items (RSIs) are considered “never events” but continue to be a source of patient harm. This article discusses the various factors that increase risk of RSIs and strategies to prevent them, such as a consistent counting process and fostering a culture of safety that encourages speaking up and a non-punitive response to errors.

Cancer drug shortages are creating dire circumstances for some patients.

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Lovelace B, Jr, Kopf M. NBC. April 11, 2023.

Shortages of life-saving cancer drugs have been a problem for many years and were exacerbated by the COVID-19 pandemic. This news article reports that low profitability of manufacturing generic drugs contributes to this shortage. Until these cancer drugs are available, many patients will receive no treatment, or treatment that is less than ideal.

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.

What's changed 1 year after RaDonda Vaught's conviction?

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Bean M, Carbajal E. Becker's Hospital Review. March 29, 2023.

The RaDonda Vaught conviction reverberated throughout health care and marked weaknesses in systems response to errors and the clinicians who make them. This news article examines how health care organizations renewed efforts to establish and nurture a culture of safety and error reporting in service of safe patient care and learning from mistakes.

Minnesota lets nurses practice while disciplinary investigations drag on. Patients keep getting hurt.

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Hopkins E, Kohler J. ProPublica. April 3, 2023.

Systemic bureaucracy can contribute to process gaps that result in needless complexities and failure. This news story outlines how inefficiencies in disciplinary investigations can enable clinicians with poor and questionable care records to practice over time.

Implement strategies to prevent persistent medication errors and hazards.

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ISMP Medication Safety Alert! Acute care edition. March 23, 2023;28(6):1-4.

Medication mistakes are recognized contributors to patient harm. This article discusses medication errors that continue to occur despite established practices that, if applied, can mitigate error occurrence. Recommended areas of focus include reducing emphasis on the “Five Rights” to address system problems, enhancing medication list accuracy, and improving neuromuscular blocking agent storage.

The prisoner.

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Kent S. NJ.com. March 12, 2023.

Heuristics, uncertainty, and bias are contributors to diagnostic error, overuse, and treatment delay. This story describes the care experience of an adolescent patient whose rare immune system condition was initially diagnosed as being psychological in origin, which contributed to persistent misdiagnosis.

Senators threaten consequences after VA confirms 4 deaths tied to computer system tested in Spokane.

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Donovan-Smith O. Spokesman Review. March 15, 2023.

Implementations of electronic health record (EHR) systems are complex efforts that have the potential for injury, should failure occur. This article discusses the Veterans Affairs EHR implementation project that is associated with six incidents of patient harm and calls for improvement at the federal level.

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