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 1556 Results

'Nobody cared': Women who have reported mistreatment while giving birth say CDC report validates their trauma. Advocates call for systemic change in treatment of pregnant people.

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Dwyer D, See P. ABC News. November 28, 2023.

Lack of respect for the concerns of patients and sensitivity to their situation detract from their safety and trust in the health care system. This story relates firsthand experience of maternal mistreatment of those harmed while receiving care.

Intravenous (IV) push medications – bridging the gap between education and clinical practice.

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ISMP Medication Safety Alert! Acute Care. November 2, 2023;28(22):1-4.

Intravenous (IV) push medication administration is a primary therapeutic approach where process gaps can result in harm. This article examines existent presence of recognized safe practice education in close to 200 surveyed nursing programs to assess the teaching of standardized practice behaviors at the student level and recommend strategies to embed IV safety into instruction efforts.

Healthcare wants to fly as high as the aviation industry. Can it?

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Twenter P. Becker's Clinical Leadership. October 30, 2023.

Health care has long held commercial aviation as a beacon to guide patient safety improvement work. This article examines how well aviation safety mechanisms map to medical care safety efforts such as checklists, just culture and operating room black boxes.

Prescription for disaster: America's broken pharmacy system in revolt over burnout and errors.

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Le Coz E. USA Today. October 26, 2023.

Chain pharmacies provide prescriptions in an environment that facilitates error due to production pressures, poor error reporting, and a lack of safety culture. This feature story examines working conditions at primary retail pharmacies in the United States and draws from staff experiences, industry data and frontline evidence to illustrate the problem as a threat to patient safety.

Doctors wrestle with A.I. in patient care, citing lax oversight.

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Jewett C. New York Times. October 30, 2023

US Food and Drug Administration regulation and review is noted as having gaps in process that can affect patient safety. This article discusses reasons for the reluctance of physicians to fully embrace the use of artificial intelligence tools approved by the FDA in their practice. The concerns include lax regulation, poor product development transparency and lack of robust real-world accuracy data.

The hospital ran out of her child's cancer drug. Now she's fighting to end shortages.

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Noguchi Y. Health Shots and All Things Considered. National Public Radio. October 23, 2023.

Drug shortages, while often discussed as a system failure, demonstrate harm at an individual level. This story highlights the work of a patient activist who was inspired by the threat to her daughter’s care posed by a lack of chemotherapy availability, to provide needed medications during system disruptions to keep patients safe.

Temporarily holding medication orders safely in order to prevent patient harm.

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ISMP Medication Safety Alert! Acute care edition. October 19, 2023;28(21):1-4.

Process disconnects can cause administration mistakes that lead to harm. This article discusses reasons for holding medications and how workflow issues can contribute to medication temporary stop order problems. Recommendations for improvement include examining electronic health record alerts, assigning one prescriber to oversee medication reconciliation, and instituting a policy on hold orders.

Achieving a successful patient safety program with implementation of a harm reduction strategy.

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Cohen JB. APSF Newsletter. 2023;38(10):93-95.

Zero harm, while a laudable goal, has been shown to have unintended consequences. This commentary calls for a morally neutral approach to human error, an elimination of blame in favor of a just culture, and harm reduction efforts that target the system instead of the individual.

Early identification and evaluation of severe pressure injuries.

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Quick Safety. October 2023;70:1-2.

Pressure injuries are a significant and preventable patient safety threat. This article summarizes recommended actions to assist health care teams in mitigating harmful healthcare-acquired pressure ulcers including recognition of conditional risks and educational strategies.

Pharmacy-led medication reconciliation is best practice.

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Tanski MC. Pharmacy Times Health Systems edition. September 2023;12(5):34-35.

Medication reconciliation should be completed at admission, discharge, and during transitions of care. This article describes the impacts of pharmacist involvement, including lower hospital readmissions and post-discharge adverse events.

Can AI help doctors come up with better diagnoses?

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Landro L. Wall Street Journal. September 24, 2023.

Artificial intelligence (AI) is being considered as a strong contender in the effort to reduce harmful diagnostic error, but concerns as to its use exist. This article discusses how physician experience can help to address AI’s lack of ability to read nuance, data weaknesses, workflow disruptions, and biased algorithms if they except the tool’s strengths to enhance the accuracy of their practice.

Patient death tied to lack of proper escalation process for barcode scanning failures.

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ISMP Medication Safety Alert! Acute Care edition. 2023;28(19):1-3.

Lack of experience with distinct processes and products can lay the foundation for mistakes. This article examines an instance when a colonoscopy preparation product was switched with a dialysis fluid, a barcoding system didn’t recognize the substitution, and a patient died. Barcode identification, solution availability and staffing improvements are discussed to minimize opportunities for the systemic failures contributing to harm.

RFID tags reduce restocking errors of anesthesia medications.

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Banks MA. Specialty Pharmacy Continuum. September 15, 2023.

Radiofrequency identification (RFID) devices are being used to improve processes in the operating room and prevent errors. This article examines the use of RFID tracking to build reliability into operating room anesthesia medication refiling process. The experience at one hospital found that the RFID process reduced errors, while increasing the task completion time.

California pharmacies are making millions of mistakes. They’re fighting to keep that secret.

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Peterson M. Los Angeles Times. September 5, 2023.

Safe practice in community pharmacy is challenged by production pressure, workforce shortages, and multitasking. This story examined the mistakes made at major retail pharmacy chains in California. It provides examples perpetrated across the industry to target universal areas of needed improvement and potential strategies to address them.

How Columbia ignored women, undermined prosecutors and protected a predator for more than 20 years.

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Fortis B, Bell L. Pro Publica. September 12, 2023.

Sexual abuse of a patient is a never event. This article discusses how criminal behavior remained latent at a large health system due to persistent disregard of patient concerns, which enabled a serial sexual abuser to continue to practice medicine. The harm to the victims and fear of the peers who knew of the situation and were not psychologically safe enough to report it, are discussed.

Uncovering the shocking dangers of misdiagnosis.

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Graedon T. People’s Pharmacy. Show 1355. September 8, 2023.

Misdiagnosis continues to impact the safety of health care. This podcast with David Newman-Toker discusses foundational issues that detract from diagnostic safety and examines how teamwork, training, technology, tuning can make the process more reliable. Strategies for patients to play a role in their diagnostic process are also discussed.

‘Dr. Google’ meets its match: Dr. ChatGPT.

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Leonard A. KFF Health News. September 12, 2023.

The use of artificial intelligence (AI) holds potential for health care improvement that is beginning to be documented. This article discusses ChatGPT in the context of wide availability of internet search tools as a mechanism for patients to find answers to clinical questions. It summarizes clinicians’ concerns about the tools and strategies to being used to ensure the accuracy and safety of these searches.

‘The Retrievals’ reveals painful experiences of female patients are often ignored.

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Desjardins L. PBS NewsHour. August 29, 2023.

Disregard for women’s pain is a persistent problem in health care. This news segment discusses a podcast highlighting a pattern of dismissal of patient concerns that resulted in harm and allowed fentanyl diversion by a nurse with substance abuse disorder to go undetected.

Dangers and deaths around black pregnancies seen as a ‘completely preventable’ health crisis.

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West S. KFF Health News. August 24, 2023.

The challenge of unsafe maternal care is gaining deserved attention across the system spectrum. This article discusses the preventative nature of many barriers to safe care Black mothers face including lack of health insurance, limited access to prenatal care and disrespect for concerns during care encounters.

Hospital bosses ignored months of doctors' warnings about Lucy Letby.

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Moritz J, Coffey J, Buchanan M. BBC News. August 19, 2023.

Whistleblowers can identify the presence of systemic failures, but the organization is responsible for acting on their reported concerns. This article summarizes the range of breakdowns that contributed to a British nurse serial murderer, who, despite warnings from others, continued to harm babies over several years.

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